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Frequently Asked Questions

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Frequently Asked Questions

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Are there any special components that should be included in medical record documentation?

Yes. Medical records (including records related to a clinical research study) should be complete, legible, and include the following information:

  • Reason for encounter, relevant history, findings, test results and date of service
  • Assessment and impression of diagnosis
  • Plan of care with date and legible identity of the observer
  • Documentation that supports that the rendering/billing provider indicated on the claim is the healthcare professional providing the service
  • Records should not only substantiate the service performed, but also the required level of care


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