• Reason for the encounter and relevant hx, physical exam findings, prior diagnostic test results
• Assessment, clinical impression or dx
• medical plan of care
• Date and legible identity of the observer
• If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred
• Past and present diagnoses should be accessible to the treating and/or consulting physician
• appropriate health risk factors should be identified
• The patient's progress, response to, and changes in treatment, and revision of diangosis should be documented
• Current CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

S = Subjective

O = Objective

A = Assessment

P = Plan   

C = Chief Complaint, presenting problems, subjective statements

H = History: social, physical history of presenting problems, as well as contributing info

E = Examination, including extent of body systems examined

D = Details of problem and complaints, etc

D = Drugs and dosage - current med list

A = Assessment of observations

R = Return visit information

Late Entry -

• supplies additional information that was omitted from the original entry
• bears current date, is added ASAM and written only if the person documenting has total recall 

Addendum

• used to provide info that was not available at the time of the original entry
• should be timely and bear the current date and reason for the addition or clarification of info being added to the record 

Records, orders, and reports not signed are considered _____

and may lead to

invalid 

recoupment of reimbursement

Are orders for clinical diagnostic tests required to be signed?

A pt chart is required to contain certain consents and authorizations.

What forms should be found in the patients MR?

• Consent for general treatment
• Consent to file insurance/medicare authorization
• assignment of benefits
• medical records release
• informed consent
• HIPAA privacy form
• Advanced Beneficiary Notice (ABN)
• Financial policy
• Non-covered Consent Form

Conditions of Participation

requirements which must be met by ASCs, critical access hospitals, SNFs, etc

• 5 years
• 6 years if a critical access hospital
• if pt is minor - statute of limitations for medical malpractice claims may not apply until the pt reaches age of majority
• immunization records must always be kept
• all documents should be destryed when discarded
• Before discarding, pt should be given right to claim old records

initiation - beginning of a new patient encounter

reduction - a decrease in a component of care

termination - discontinuation of certain items or services

Under ARRA, how much can BAs be penalized for violations of HIPAA?

is it civil or criminal?

civil

civil enforcement actions and civil penalties have been increased to up to $50,000 per violation, maxing at $1.5 million per year for repeats of the same violation.

used to indicate to Medicare that you expect the item or serviceto be denied as not reasonable  and necessary and you do not have an ABN signed by the beneficiary.

Medicare will automatically deny this claim and these items will not be subject to a complex medical review