Medical Record Checklist for Accurate Billing

This checklist outlines the key components of a complete medical record for accurate medical billing. It ensures proper documentation exists to support submitted claims.

Patient Information:

• Demographics: Face sheet, registration form with accurate details like name, address, phone numbers (home & mobile), email, date of birth, sex, race, occupation, employer information, and emergency contact details.

• Financial Information: Insurance details including payer name, address, phone number, subscriber name, policy number, and responsible party information (name, address, phone number, employer details, and relationship to insured).

Authorization Forms:

• Consent for Treatment: Written consent obtained for procedures beyond routine care. This consent should detail:

• Diagnosis and recovery potential

• Recommended treatment plan

• Risks and benefits of treatment and non-treatment options

• Expected success rate and recovery timeline

• Assignment of Benefits: Authorization for the patient’s insurance company to make direct payments to the provider for received treatment.

Release of Information:

• A valid authorization for releasing protected health information (PHI) must include:

• Patient identification verification

• Description of information to be disclosed

• Name of authorized party releasing and receiving the information

• Patient’s signature authorizing the release

Clinical Documentation:

• Treatment History: This includes:

• Chief complaints (reason for visit)

• Medical history

• Vital signs

• Physical examination findings

• Surgical history

• Obstetric history (if applicable)

• Allergies

• Family history

• Immunization history

• Lifestyle habits (exercise, diet, alcohol, smoking, drug use)

• Developmental history (if applicable)

• Progress Notes: Documentation of new information and changes in the patient’s condition during treatment. These notes include:

• Observations of physical and mental health

• Sudden changes in condition

• Vital signs at intervals

• Food intake

• Bladder and bowel function

• Physician Orders and Prescriptions:

• Orders for tests, procedures, or surgeries with instructions for the healthcare team.

• Prescriptions for medications, medical supplies, or equipment for home use.

• Consult Notes: Findings and opinions from consulting physicians.

• Lab Reports: Results of laboratory tests.

• Radiology Reports: Results of radiology studies (X-rays, etc.).

• Nursing Notes: Separate documentation by nurses, including:

• Patient assessment

• Processes performed

• Interventions provided

• Evaluation of outcomes

Additional Documentation:

• Medication List: Comprehensive list of all medications (prescription and non-prescription), including dosage, route, and schedule.

• HIPAA Notice of Privacy Practices: This notice informs patients about their privacy rights regarding their protected health information (PHI) as mandated by HIPAA.

Patient Confidentiality:

• The medical office has a legal responsibility to ensure patient privacy and secure their PHI. Disclosing PHI without authorization is a violation of HIPAA’s Privacy Rule.

• Security Measures: Develop a formal process to ensure compliance, including:

• Policies and procedures for data protection

• Internal audits

• Contingency plans for emergencies

• Safeguards to prevent unauthorized access

• Access authorization verification protocols

• Equipment control procedures

• Visitor handling policies

• Staff training on PHI protection measures

By following this checklist, medical practices can ensure their medical records are complete and accurate, facilitating proper billing and promoting patient privacy.

Read more: https://www.allzonems.com/12-point-medical-record-checklist-what-is-included-in-a-medical-record/