Cpma Practice Exam A

SOAP {Ans: } Subjective, Objective, Assessment, PlanCHEDDAR {Ans: } Chief complaint, Hx, Exam, Details of problem/complaint, Drugs & dosages, Assessment, Return visitSubjective {Ans: } Pt complaintObjective {Ans: } Provider observationAssessment {Ans: } Medical DxPlan {Ans: } TreatmentYou are performing an audit of e/m services for a FP office. In the encounter you read the physician ordered and reviewed a differential WBC. What elements would you expect to see in the medical records? {Ans: } Patient ID, assignment of benefits, pt's medical hx, immunizations, physical examination, lab report, clinical impression & physician orders. When labs are ordered, there must be a copy of the order and the lab report that the physician has reviewed.What is the minimum requirement for the signature of the author of an entry in the medical records? {Ans: } The first initial, last name and credentialsBased on JCAHO accreditation guidance for personal data, what two elements must be evident in the medical records? {Ans: } Personal biographical data and consent for Treatment or authorization for Treatment form.What is a comprehensive/focus review audit? {Ans: } A large number of claims are selected for review that might be focused on specific procedure and/or dx codesWhat is RAT-STATS used for