"Providing written proof or support of something that has been done, was observed, or needs to be done."
What is Documentation?
100
Contains all required information in the appropriate fields.
What is Complete.
100
Contains required fields, radio buttons and free text area.
What is a Structured Note.
100
A ______ in the page tab indicates there are fields/areas that can be edited.
What is Pencil.
100
Only the person who created the Note can void the Note. True or False.
What is True.
200
Member demographics, Assessments, Authorizations, Notes
What are examples of where proper documentation is important.
200
Specific, free of spellings errors, uses only standard abbreviations and acronyms.
What is Clear.
200
Where you would find letters that have been sent to the member.
What is the Notification Summary.
200
Good documentation protects the Member and everyone associated with their care.
What is Quality.
200
Opinions, conjecture, assumptions, ideas and guesses.
What is Subjective.
300
Complete, Concise, Clear, Accurate, Timely.
What are the Elements of Good Documentation.
300
Contains all necessary data for others to understand the message, but without information that is not relevant to medical outcome in any way.
What is Concise.
300
What note would be used when the member has a primary insurance and we are the secondary insurance>
What is the COBv2 note.
300
If it wasn't documented __________________ .
What is It never happened or It wasn't done.
300
Better Health Outcomes at Lower Costs.
What is Centene's Mission.
400
Abbreviations and acronyms that are not standard, entries that do not make sense, incomplete information, personal opinions, conclusions, or speculation.
What are Elements of Poor Documentation.
400
Information is correct, required fields complete, information is consistent.
What is Accurate.
400
Documentation that takes place after the initial interaction, but needs to be added to the original note.
What is a Late entry.
400
_____ should never be entered in the Alert Pod.
What is PHI or information that should be permanently maintained.
400
Facts that are based on observation.
What is Objective.
500
Sets national standards to protect individual personal health information.
What is HIPPA.
500
Dates and times are entered correctly, chronology of events is accurate and makes sense.
What is Timely.
500
This is indicated by a red asterisk.
What is a required field.
500
You can print out a hard copy of a note or multiple notes by clicking _______________ .
What is Create PDF.
500
The Member, the Provider, the Providing Facility, the Health Plan and others involved in the members care.