CPMA: Medical Record Standards and Documentation Guidelines

CPMA: Medical Record Standards and Documentation Guidelines The following should be included in what type of encounter; DOS,total time by individual modality, signature, and any addtional info relating to progress. - Correct ️️ Therapy Treatment Encounter For each day of PT tx encounter provided to a Medicare patient, what should be documented for the modalities? - Correct ️️ Total timed tx by individual modality and total tx time in minutes. For therapy services, what is the reason for a progress note? - Correct ️️ To provide justification for the medical necessity of tx information. The type of contrast, amount used, and the route of administration should be documented for what type of report? - Correct ️️ Radiology report What is an informed consent? - Correct ️️ Explains treatment and plan ahead of procedure, gone over with patient by the provider. Prior to a patient undergoing a procedure, what should be obtained? - Correct ️️ Informed Consent, signed by patient. Forms, E/M documentation, operative reports, ancillary services are all what? - Correct ️️ Components of a medical record Header, indications for surgery, detail or body, findings are all what? - Correct ️️ Components of an operative report. What does CHEDDAR stand for? - Correct ️️ Chief complaint History of present illness