You 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? - ✔✔-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? -
✔✔-The first initial, last name and credentials
Based on JCAHO accreditation guidance for personal data, what two elements must be evident in the
medical records? - ✔✔-Personal biographical data and consent for Treatment or authorization for
Treatment form.
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