solutions 2024/2025
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 HIPAA: - ANSWER-For a
six (6) year period of time