Tx Record Revw Audit Tool for multiple records-NE&EMPIRE
4 Pages
English
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Tx Record Revw Audit Tool for multiple records-NE&EMPIRE

-

Downloading requires you to have access to the YouScribe library
Learn all about the services we offer
4 Pages
English

Description

Treatment Record ReviewAudit Tool(Northeast and Empire Region)Provider Name DiscPractice Name Solo GroupProvider ID NumberProvider AddressCity State ZipPhone FaxOffice Contact NameVerbal Summary of audit results given to?Discussion of Clinical Practice Guidelines? Yes NoReason for Review Quality Review Action Plan Follow-up Routine Clinical Record Review Recredentailing OtherAffected AccountsRec 1 Rec 2 Rec 3 Rec 4 Rec 5 CommentsDiagnosisAgeInitialsSTANDARD1. Each page in the treatment record contains the enrollee's name or ID number2. Each treatment record includes the enrollee's address, employer or school name, home telephone number, work telephone number, emergency contacts, marital status or legal status, appropriate consent forms, and guardian information if relevant.3. All entries in the treatment record include the responsible clinician's name, professional degree, and relevant identification number, if applicable.4. All entries in the treatment record are dated.5. The treatment record is legible to someone other than the writer.6. Relevant medical conditions are listed, prominently identified, and revised as appropriate in the treatment record.7. Presenting problems, ...

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