AAPC CPMA Practice Exam Study Correct Questions & Answers!!

What elements must be in a medical record - ANSWER 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? - ANSWER 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? - ANSWER 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? - ANSWER Discard it in a locked shredding receptacle When must ABNs be signed? - ANSWER 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? - ANSWER S in SOAP and H in CHEDDAR Patients can request copies of disclosure of PHI under