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Initial Sheet Medical Case Sheet Audit

The document provides a checklist for initial patient visit documentation, including ensuring the admission record is complete, informed consent is signed, patient details are documented, chief complaints and their timing/intensity are recorded, clinical exam findings and diagnostic tests are included, a diagnosis and treatment plan are stated, treatments rendered are noted, and insurance claims are supported by the medical record documentation.

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Srinivas Polikepati
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© Attribution Non-Commercial (BY-NC)
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847 views

Initial Sheet Medical Case Sheet Audit

The document provides a checklist for initial patient visit documentation, including ensuring the admission record is complete, informed consent is signed, patient details are documented, chief complaints and their timing/intensity are recorded, clinical exam findings and diagnostic tests are included, a diagnosis and treatment plan are stated, treatments rendered are noted, and insurance claims are supported by the medical record documentation.

Uploaded by

Srinivas Polikepati
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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Initial Visit Documentation Checklist Patient name: IP number:

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Fullness of the Admission record Informed Consent Form signed by patient Signature of Doctors/ consultant Patient name on each page of the record. Chief complaint documented. Timing and intensity of complaints documented. Causation: accident, injury, and etiology documented. Details of complaint documented. Are Clinical exam findings documented ? Written radiographic findings documented and signed. Diagnostic impression documented. Is there a diagnosis in the record ? Are Diagnostic tests documented and filed? Is there a treatment plan for this condition? Treatment/services rendered documented. Health record is complete and legible. Are all details of the initial nursing assesment filled? Are all details of the physiotherapy initial assessment filled? Health insurance claims are APPROPRIATE and SUPPORTED by documented medical necessity in the record

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MLC Details

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