Chapter 4: Documentation Standards Flashcards
What does the National Committee for Quality Assurance (NCQA) has established?
A set of minimum standards for medial record documentation.
Does each page in the record should contain the patient’s name of ID number?
Yes.
All entries are authenticated by?
The author, signature, initials, or unique electronic identity.
The medical record is legible to others?
Yes.
What does the problem list includes?
Illness and Medical conditions.
If the patient has no known illness or condition that does the medical record includes?
A flow sheet for ongoing health maintenance.
Does Medication allergies and adverse reactions are prominently notes?
Yes.
What does Past Medical history includes?
Significant accidents, illness and surgeries.
If a consultation is ordered what should be done?
A note from the consultant is in the record.
Does treatment plans should be consistent with the diagnoses?
Yes.
