AMA CPT® Assistant - 1995 Issue 1 (January)
Medical Records Check-up (Spring 1995)
Spring 1995 pages 9-11 Medical Records Check-up Do you .... Write legibly or use transcription? Use clear, concise language? Date and sign entries? (Particularly if in a group practice?) Avoid improper alteration of the medical record? Avoid using non-standard abbreviations? Document what a patient tells you and what you tell a patient? Obtain and file patient authorization for record release? (Review applicable state laws on release of medical records) Include consulting physicians reports/notes? Include disability reports and other information from others participating in patient's care? Sign reports and dictation only after review? Medical Records Check-up. CPT® Assistant. 1995; Spring...
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