1-3 soap

These flashcards cover key terms and concepts related to professional communication and health records management as discussed in the lecture notes.

Third Person

Writing style in professional communication where the writer does not refer to themselves or use emotions, e.g., ‘The therapist helped the client.’

Active Voice

A grammatical construct in which the subject performs the action of the verb, e.g., 'Client stated…'

HIPAA

Health Insurance Portability and Accountability Act, which protects personal health information.

Protected Health Information (PHI)

Any information about health status, provision of health care, or payment for health care that can be linked to an individual.

Documentation Principle

If it is not documented, it did not happen.

Jargon

Terminology used within a particular profession or group that may be unclear to outsiders.

EHR

Electronic Health Record; a digital version of a patient’s paper chart that is more comprehensive.

EMR

Electronic Medical Record; a digital record maintained by a single healthcare provider.

PHR

Personal Health Record; a patient-controlled health record typically stored in a patient portal.

Records Retention

The policy regarding how long documentation must be maintained by a provider or facility.

Fraud

Intentional deception for personal or financial gain in healthcare contexts.

Plagiarism

Presenting someone else's work or ideas as one’s own.

Litigation Do's

Recommendations for clear and concise documentation that limits interpretation by attorneys.

Litigation Don'ts

Avoid unclear or vague statements in documentation that could lead to misinterpretation.

CPT Codes

Current Procedural Terminology codes used to describe medical, surgical, and diagnostic services.

Durable Medical Equipment (DME)

Medical equipment that is reusable and primarily used to serve a medical purpose.

Medicare Part A

Hospital Insurance that covers inpatient hospital stays.

Medicare Part B

Medical Insurance that covers outpatient care.

Medicare Part C

Medicare Advantage Plans that allow coverage through private insurers.

Medicare Part D

Prescription Drug Coverage which helps cover the cost of medications.

Medigap

Supplemental insurance that helps cover costs not covered by Medicare.

Maintenance Programs

Programs designed to help maintain current function and prevent decline.

Rehabilitative Therapy

Therapy aimed at restoring or improving function and health.

Aides

Assistants who may perform routine tasks under supervision but cannot provide skilled therapy.

Email Protocols

Guidelines for professional email communication, including encryption and permission to send.

State Laws

Regulations that dictate who can access patient information and what release forms are needed.

Abbreviations

Shortened forms of words or phrases to facilitate easier documentation.

Caregiver Training

Instruction designed to equip caregivers with skills to assist in maintenance programs.

Fall Risk

The likelihood of an individual falling, which is a safety concern in healthcare.

Breach of HIPAA

Unauthorized access or disclosure of health information, which is a serious offense.

ICD 10 Codes

International Classification of Diseases codes for classifying health conditions and diseases.

Maintenance Tasks

Routine activities that do not require skilled therapy and can be performed by non-professionals.

Client Participation

Active engagement of the client in their therapy process, as opposed to mere attendance.

Charge Sheets

Documents that outline the services provided and any associated costs.

Electronic Records Access

Limitation on who can view electronic health records to protect patient confidentiality.

Billable Services

Therapeutic services that can be billed to insurance for reimbursement.