Final Exam - weeks 7, 8

what is the synthesis of subjective and objective evidence to arrive at a diagnosis?

assessment

what is included in the assessment

ICD-10 Codes (diagnoses codes)

Visit summary

what does ICD-110 stand for

International Classification of Diseases, 10th revision

what are ICD-10 codes used for

global system for coding causes of death and diseases developed by WHO

what is the minimum and maximum number of characters for ICD-10 codes

4, 7

what is the ICD code M99.01 used for

segmental and somatic dysfunction of cervical region

what is M54.2 used for

cervical pain

what is S33.5XXA used for

sprain of ligaments of lumbar region, initial encounter

what is M54.4 used for

lumbar spine pain

what is M99.03 used for?

segmental and somatic dysfunction of lumbar region

what is M51.06 used for

IVD disorders with myelopathy in lumbar region

what is ICD code for segmental and somatic dysfunction of thoracic region

M99.02

which ICD code gets listed as the Primary?

the diagnoses that prompted the visit

written summary of that day's care with anticipated next steps in the management of the patient.

visit summary

where does the visit summary get entered

in the notes section of Assessment

An outline of the next steps in a patient's care based on information gathered in the Subjective, Objective, and Assessment.

Plan

The ____ details treatments the patient received during the current visit and what will happen next.

plan

what is included int he Plan

procedures

diagnostic imaging orders

lab orders

care plan

next appointment

visit billing information

used to document segments/extremities adjusted by the supervising doctor.

Clinician adjustment performed

used to document the name and matric number of the student intern administering the care.

student

used to document segments/extremities adjusted by the student intern.

Student adjustment performed

Comprehensive documentation outlining a patient's specific health needs, goals, and the care they will receive.

A roadmap for healthcare providers to ensure consistent, coordinated, and patient-centered care.

care plan

what are the care plan rules

1. laid out in way for patient and other providers to see planned improvement

2. ability to change

3. if altered, documentation should reflect that

4. updated/reviewed following re-eval

5. treatment consistent with diagnosis

how do you access the care plan

1. select care plan on progress note

2. select patient care and support plan from the add template section

A concise and specific description of the patient's condition or problem including the rationale for the diagnosis including the level of segmental dysfunction when present.

diagnostic statement

what is nociceptive pain?

what is Neuropathic pain?

what is Nociplastic pain?

non-neural tissue

somatosensory nervous system dysfunction

result of central or peripheral sensitization

are active therapies performed by the patient or doctor

patient

what is a tool that can be used to track outcome assessment/screening score progression

provided as a graphi

flowsheets

how can you access flowsheets

progress notes

patient hub