passed
1. What elements must be in a medical record Patient ID, Assignment
of
Benefits, medical histo-
ry, immunizations,
physical exam, lab
report, clinical
impression, physician
or- ders
2. What is the minimum signature First initial, Last Name
assignment of the author of entry in the and credentials
medical record?
There must be a
3. Based on the JC accreditation guidelines for pa- tient information
personal data, what 2 elements must be sheet that contains
evident in the medical record? biographi- cal data,
name, address,
etc. along with
authoriza- tion for
treatment whether it is
an oflce visit, diagnos-
tic services or surgical
pro- cedure.
4. What is the appropriate way to dispose of PHI
that is no longer needed? Discard it in a locked
shredding receptacle
5. When must ABNs be signed? Far enough in
advance that the
beneficiary or rep-
resentative has time to
consider the options
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11
, AAPC CPMA Practice Exam Study questions and answers already
passed
and make an
informed deci- sion.
6. SOAP and CHEDDAR are two formats of medical record S in SOAP
and H in CHED-
documentation. Which section of each format DAR
would you find the patient's history?
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