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What elements must be in a medical record - ✔✔-Patient ID, Assignment of Benefits, medical history,
immunizations, physical exam, lab report, clinical impression, physician orders
What is the minimum signature assignment of the author of entry in the medical record? - ✔✔-First
initial, Last Name and credentials
Based on the JC accreditation guidelines for personal data, what 2 elements must be evident in the
medical record? - ✔✔-There must be a patient information sheet that contains biographical data, name,
address, etc. along with authorization for treatment whether it is an office visit, diagnostic services or
surgical procedure.
What is the appropriate way to dispose of PHI that is no longer needed? - ✔✔-Discard it in a locked
shredding receptacle
When must ABNs be signed? - ✔✔-Far enough in advance that the beneficiary or representative has
time to consider the options and make an informed decision.
SOAP and CHEDDAR are two formats of medical record documentation. Which section of each format
would you find the patient's history? - ✔✔-S in SOAP and H in CHEDDAR
Patients can request copies of disclosure of PHI under HIPAA: - ✔✔-For a six (6) year period of time
When can a RAC extrapolate the overpayment(s) on claims? - ✔✔-If a RAC can demonstrate a high level
of error, the RAC can then extrapolate the findings and request a refund.