The document discusses decision-making criteria for interventions from the perspectives of both practitioners and physicians, outlining various factors such as intuition, professional experience, and data from studies. It includes patient registration and encounter forms for a clinic, detailing personal information, insurance coverage, and billing details for a patient named Jane Doe. The document emphasizes the importance of systematic decision criteria in both healthcare practices and administrative processes.

1. Situations 1 and 2: Making Decisions About Interventions*
Situation 1
Think back to a client (individual, family, group, agency, or
community) with whom you have worked. Place a check mark
next to each criterion you used to make your practice decision.
If you have not yet worked with a client, think of the criteria on
which you would probably rely.
____1. Your intuition (gut feeling) about what will be
effective
____2. What you have heard from other professionals in
informal exchanges
____3. Your experience with a few cases
____4. Your demonstrated track record of success based on
data you have gathered systematically and regularly
____5. What fits your personal style
____6. What was usually offered at your agency
____7. Self-reports of other clients about what was helpful
____8. Results of controlled experimental studies (data that
show a method is helpful)
____9. What you are most familiar with
____10. What you know by critically reading professional
literature
Situation 2
Imagine you have a potentially serious medical problem and you
seek help from a physician to examine treatment options. Place
a check mark next to each criterion you would like your
physician to rely on when he or she makes recommendations
about your treatment.
____1. The physician’s intuition (gut feeling) that a method

2. will work
____2. What he or she has heard from other physicians in
informal exchanges
____3. The physician’s experience with a few cases
____4. The physician’s demonstrated track record of success
based on data he or she has gathered systematically and
regularly
____5. What fits his or her personal style
____6. What is usually offered at the clinic
____7. Self-reports of patients about what was helpful
____8. Results of controlled experimental studies (data that
show a method is helpful)
____9. What the physician is most familiar with
____10. What the physician has learned by critically reading
professional literature
*From Gambrill, E., & Gibbs, L. (2017). Making decisions
about intervention. In Criticalthinking for helping
professionals: A skills-based workbook (4th ed., pp. 69–70).
New York, NY: Oxford University Press.
Module 03
Course Project - Part 1
PATIENT REGISTRATION FORM
– The People’s Clinic
– 1000 Town Square, Anytown Pennsylvania 54321
– 555-741-8529

3. PATIENT INFORMATION
atient – Mrs. Jane Doe
– Jane Smith
– 01/01/1960
- 123-45-6789
– 123 Main Street, Anytown Pennsylvania 54321
– 555-987-6543
– Nurse
– The People’s Hospital
Employer Phone – 555-456-7890
INSURANCE INFORMATION
– Jane Doe
– 123123123

4. – 00550055
insurance
IN CASE OF EMERGENCY
– 555-567-8910
– 555-678-9012
OUTPATIENT ENCOUNTER FORM
Jane Doe (chart #0987) saw Dr. Brown on 1-1-2015.
She is 5’5’’ tall and weighs 130 pounds
Her blood pressure was 120/70
Her pulse was 60
Her temperature was 98.6
This was her second visit with Dr. Brown after she was referred
by Dr. White. She is seeing Dr. Brown
for adult onset IDDM (insulin dependent diabetes mellitus).

5. Jane’s visit was only for an office visit and laboratory tests.
Dr. Brown spent 25 minutes with Jane at this
visit and ordered lab testing for Hemoglobin A1C. Jane needs
to return to see Dr. Brown in 1 month.
When Jane checked out she gave the receptionist her encounter
form which had the office visit at a cost
of $100. She paid the amount of her copayment which was $20.
[NAME OF PRACTICE]
REGISTRATION FORM
(Please Print)
Today’s date: PCP:
PATIENT INFORMATION
s.
Marital status (circle one)
Single / Mar / Div / Sep / Wid

6. Is this your legal name? If not, what is your legal name?
(Former name): Birth date: Age: Sex:
Street address: Social Security no.: Home phone no.:
( )
P.O. box: City: State: ZIP Code:
Occupation: Employer: Employer phone no.:
( )
Chose clinic because/Referred to clinic by (please check one
Other
Other family members seen here:
INSURANCE INFORMATION
(Please give your insurance card to the receptionist.)
Person responsible for bill: Birth date: Address (if different):
Home phone no.:
/ / ( )

7. Occupation: Employer: Employer address: Employer phone no.:
( )
Is this patient covered by
Please indicate primary
Subscriber’s name: Subscriber’s S.S. no.: Birth date: Group no.:
Policy no.: Co-payment:
/ / $
Other
Name of secondary insurance (if applicable): Subscriber’s
name: Group no.: Policy no.:
Other
IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address):
Relationship to patient: Home phone no.: Work phone no.:
( ) ( )

8. The above information is true to the best of my knowledge. I
authorize my insurance benefits be paid directly to the
physician. I understand
that I am financially responsible for any balance. I also
authorize [Name of Practice] or insurance company to release
any information required
to process my claims.
Patient/Guardian signature Date
[Name of Practice]REGISTRATION FORM
Todays date: PCP: Patients last name First Middle: salutation:
salutation_2: Yes: No: If not what is your legal name: Former
name: Birth date: Age: Sex: Street address: Social Security no:
Home phone no: PO box: City: State: ZIP Code: Occupation:
Employer: Employer phone no: Chose clinic becauseReferred to
clinic by please check one box: Family: Friend: Close to
homework: Other: Yellow Pages: Dr: Insurance Plan: Hospital:
Other family members seen here: Person responsible for bill:
Birth date_2: Address if different: Home phone no_2: Is this
person a patient here Yes No: undefined: undefined_2:
Occupation_2: Employer_2: Employer address: Employer phone
no_2: Is this patient covered by insurance Yes No: undefined_3:
undefined_4: Insurance: Insurance_2: Insurance_3: Insurance_4:
Insurance_5: Welfare Please provide: Insurance_6: Insurance_7:
Insurance_8: Other_2: Subscribers name: Subscribers SS no:
Birth date_3: Group no: Policy no: Patients relationship to
subscriber Self Spouse Child Other: undefined_5: undefined_6:
undefined_7: undefined_8: Name of secondary insurance if
applicable: Subscribers name_2: Group no_2: Policy no_2:
Patients relationship to subscriber Self Spouse Child Other_2:
undefined_9: undefined_10: undefined_11: undefined_12: Name
of local friend or relative not living at same address:
Relationship to patient: Date:

9. Outpatient Encounter Form
Patient Information
Billing Information
Visit Information
Patient ID number
Primary
Visit date
Patient name
Primary ID number
Visit number
Address
Primary group number
Rendering physician
City/State
Secondary
Referring physician
Social Security number
Secondary ID number
Reason for visit

10. Phone number
Secondary group no.
Date of birth
Cash/credit card
Age
Other billing
E/M Modifiers
Procedure Modifiers
Other Modifiers
24 — Unrelated E/M service during postop.
22 — Unusual, excessive procedure
25 — Significant, separately identifiable E/M
50 — Bilateral procedure
57 — Decision for surgery
51 — Multiple surgical procedures in same day

11. 52 — Reduced/incomplete procedure
55 — Postop. management only
59 — Distinct multiple procedures
CATEGORY
CODE
MOD
FEE
CATEGORY
CODE
MOD
FEE
Office Visit — New Patient
Wound Care
Minimal office visit
99201
Debride partial thick burn
11040

12. 20 minutes
99202
Debride full thickness burn
11041
30 minutes
99203
Debride wound, not a burn
11000
45 minutes
99204
Unna boot application
29580
60 minutes
99205
Unna boot removal
29700
Other

13. Other
Office Visit — Established
Supplies
Minimal office visit
99211
Ace bandage, 2”
A6448
10 minutes
99212
Ace bandage, 3"-4”
A6449
15 minutes
99213
Ace bandage, 6”
A6450

14. 25 minutes
99214
Cast, fiberglass
A4590
40 minutes
99215
Coban wrap
A6454
Other
Foley catheter
A4338
General Procedures
Immobilizer
L3670
Anascopy
46600

15. Kerlix roll
A6220
Audiometry
92551
Oxygen mask/cannula
A4620
Breast aspiration
19000
Sleeve, elbow
E0191
Cerumen removal
69210
Sling
A4565
Circumcision
54150
Splint, ready-made
A4570

16. DDST
96110
Splint, wrist
S8451
Flex sigmoidoscopy
45330
Sterile packing
A6407
Flex sig. w/ biopsy
45331
Surgical tray
A4550
Foreign body removal—foot
28190
Other
Nail removal
11730

17. OB Care
Nail removal/phenol
11750
Routine OB care
59400
Trigger point injection
20552
OB call
59422
Tympanometry
92567
Ante partum 4–6 visits
59425
Visual acuity
99173
Ante partum 7 or more visits
59426

18. Other
Other
Other Visit Information:
Fees:
Lab Work to Order:
Total Charges:
$
Referral to:
Copay Received:
$
Provider Signature:
Other Payment:
$
Next Appointment: Total Due:
$
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