Explain the steps that are included in the creation of a medical record. Include the different sections and where they would be located in the medical record. Explain why the insurance card is considered part of the medical record in any type of health care facility.
What will be an ideal response?
1. Administrative section includes: patient registration form, acknowledgement of the receipt of notice of privacy, front and back of insurance cards, and correspondence.
2. Medical and clinical sections include: progress notes specific to one of the documentation methods, medication and allergy sections, diagnostic tests, and hospital records where applicable.
The insurance card provides the information necessary on the type of insurance, who the subscriber is, the identification numbers, as well as information on copays and billing information.
You might also like to view...
Which directional term is the opposite of anterior?
A) dorsal B) ventral C) caudal D) cephalic
Otitis media is defined as inflammation of the:
A. eardrum B. labyrinth C. mastoid process D. middle ear
The Joint Committee on National Health Education Standards recommends that students in grades 3-12 receive a minimum of ________ hours of formal health instruction each school year.
A. 20 B. 60 C. 80 D. 40
Metabolic syndrome is associated with a low body weight
Indicate whether the statement is true or false