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- 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: $ � MACROBUTTON DoFieldClick [Company Name]� Company Name, Street Address, City, State ZIP Code, phone number