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You are performing an audit of evaluation and management services for a family practice office. In the
encounter, you read the physician order and reviewed a differential WBC. Which of the following best
describes what you would expect to see in the medical record? - ✔✔-Patient identification, assignment
of benefits, patient's medical history, immunizations, physical examination, lab report, clinical
impression, and physician orders.
What is the minimum signature assignment(s) of the author of an entry in the medical record? - ✔✔-The
first initial, last name and credentials
Based on Joint Commission accreditation guidance for personal data, what two elements must be
evident in the medical record - ✔✔-Personal biographical data and consent for treatment or
authorization for treatment form
As an auditor, who of the following would NOT be expected to submit operative notes? - ✔✔-Surgical
assistants
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