CPMA Practice Exam A| 25 Questions| Correct Answers

You are performing an audit of evaluation and management services for a family practice office. In the encounter, you read the physician order and reviewed a differential WBC. Which of the following best describes what you would expect to see in the medical record? - ANSWER Patient identification, assignment of benefits, patient's medical history, immunizations, physical examination, lab report, clinical impression, and physician orders. What is the minimum signature assignment(s) of the author of an entry in the medical record? - ANSWER The first initial, last name and credentials Based on Joint Commission accreditation guidance for personal data, what two elements must be evident in the medical record - ANSWER Personal biographical data and consent for treatment or authorization for treatment form As an auditor, who of the following would NOT be expected to submit operative notes? - ANSWER Surgical assistants