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Details

Report Writing and Documentation
Audiology 2
12
Audiology
Graduate
02/23/2017

Additional Audiology Flashcards

 


 

Cards

Term
Preserving exam & test results in file, must be maintained after providing services
Definition
Documenting
Term
What is an example of documenting?
Definition
Case Hx & test outcomes on audiogram form (AC, BC, speech audiometry, acoustic immittance results)
Term
Documenting:
-Significance: Crucial for continuity of ___, billing, & ___
-Implications: be ___
Definition
care; legal; thorough
Term
Summarizing the documentation
Definition
Reporting
Term
Reporting:
-Interpreting & converting documented data into report form to ___ effectively
-Be succint (___ is more)
Definition
communicate; less
Term
3 key ideas from Dr. Stach:
-___ and ___ language
*use ___ terminology
*Make it ___ and concise
Definition
Simplify; standardize; consistent; clear
Term
3 Key idea from Dr. Stach:
2. Skip the term "___"
-“A report that says the outcome was “borderline normal” does ___ tell me anything”
Definition
borderline; not
Term
3 Key ideas from Stach:
3. Communicate ___ results
-Report if anything is ___
Definition
important; abnormal
Term
What if Reliable Responses Could Not be Obtained?
-___ on the audiogram that valid thresholds could not be established
-Write a ___
-Note: reliable means ___
-Note: valid means results are ___ (e.g. represent the
listener’s thresholds)
Definition
note; letter; repeatable; true
Term
Medical Record Documentation: Purposes
-Determines ___ level
-Preserves health information to facilitate ___ care
-Keeps ___ data
-Maintains ___ data
-Helps meet ___
-___ health reporting
Definition
reimbursement; current/future; injury; scientific; regulations; Public
Term
-Record is admissible as evidence in all personal ___
legal proceedings & forms basis of ___ of all malpractice cases
-Incomplete or inaccurate records raise ___ of fact about care
-Quality documentation deters ___
-Liability often imposed if ___ can not be established
Definition
injury; defense; questions; lawsuits; facts
Term
Describe ways to reduce risk when documenting:
-Put patient’s ___ name on every page
-___, signature, ___ of practitioner on all entries
-Entries should be ___, juries often equate poor entries
with poor care
- Entries should be ___, objective, & ___ pertinent
Definition
full; Date; title; legible; specific; clinically
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