Refer to the template of a snapshot view of the medical record components and a checklist to use for compliance, shown earlier in this chapter. Use the manager’s checklist to look for consistency in the following medical record and record any deficiencies.
Checklist for documentation for the physician office record
? Patient registration form complete
? Acknowledgment of the receipt of the notice of privacy
? Authorization for disclosure of health information
? Progress notes complete
? Diagnostic test reports
? Hospital records (if applicable)
? Medication record complete
? Other pertinent records
What will be an ideal response?
Discrepancies of Medical Record
Patient registration is missing patient information, insurance information, demographics, and it is not dated.
Acknowledgement of the Notice of Privacy is not dated.
Radiology test is not dated.
Admitting History and Physical is not dated.
Operative report is not dated.
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