Which of the following is the same as a superbill?
Consent form
Assignment of benefits
Encounter form
Advanced beneficiary notice
The Correct Answer is C
A. Consent form: A consent form is a document that gives permission for medical procedures or treatments and is not the same as a superbill.
B. Assignment of benefits: Assignment of benefits is a document that allows the insurance company to pay the provider directly, not a billing form used to summarize charges.
C. Encounter form: A superbill is also known as an encounter form. It details the services provided, diagnosis codes, and charges for a patient’s visit.
D. Advanced beneficiary notice: An advanced beneficiary notice informs patients about services that Medicare may not cover and is not related to billing or charges.
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Correct Answer is B
Explanation
A. Perform orthostatic blood pressure. Orthostatic blood pressure measurements are used to assess changes in blood pressure when a patient moves from lying down to standing, not in response to emotional upset.
B. Recheck the blood pressure after a few minutes. This is the correct action, as the initial elevated reading could be due to the patient's emotional state. Waiting a few minutes and rechecking can provide a more accurate reading.
C. Measure blood pressure at the wrist. Wrist blood pressure readings are less accurate than those taken at the upper arm and are not recommended in this scenario.
D. Use the palpatory method for blood pressure. The palpatory method is used when auscultation is difficult, but it does not address the issue of an elevated reading due to emotional upset.
Correct Answer is A
Explanation
A. Subjective: The chief complaint is a patient-reported symptom or concern and is documented in the subjective section of the progress note. This section includes the patient’s personal perspective and descriptions of their symptoms.
B. Objective: The objective section includes measurable or observable data, such as vital signs and physical examination findings, not the patient’s chief complaint.
C. Review of systems: The review of systems is a systematic approach to obtaining information about the functioning of various body systems but is not specifically where the chief complaint is documented.
D. Assessment: The assessment section contains the provider’s diagnostic impressions and conclusions about the patient’s condition, rather than the chief complaint.