Remove Documentation Remove Insurance Remove Medical History
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Basics of Medical Documentation: What Aspiring Medical Billers and Coders Need to Know

Northwest Career College

Accurate documentation is essential for medical billing and coding, but many beginners struggle to understand the technical terms and guidelines. Without accurate medical documentation, insurance claims can be delayed or denied, frustrating patients and physicians. What is Medical Documentation?

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Duties and Responsibilities for Entry-Level Medical Assistants

Prism Career Institute

It’s also crucial to maintain patient confidentiality and follow Health Insurance Portability and Accountability Act (HIPAA) regulations. Obtaining background information: Before a patient sees a physician, an assistant typically discusses their medical history and makes sure the facility has an accurate record on file.

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Meeting Psychiatrists’ Technical Needs: A Practice Owner’s Guide to EHR

Valant

Customizable Note Templates The ability to create and customize templates for intake, medical history, therapy notes , and progress notes helps save time and energy. In addition, it’s important to be able to obtain prior authorization from insurance and track prescription statuses.

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What Are SOAP Notes and How Do You Write Them?

Valant

The information recorded may include symptoms, medical history, test results, diagnoses, treatment plans, prescription medications, and progress made at appointments. This information is shared with insurance companies to justify claims. Check out Valant’s clinical documentation features to learn more.

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HIPAA: Understanding Patient Confidentiality and How It Relates to Medical Assistants

Prism Career Institute

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that regulates how patient information is managed, protecting their privacy. Medical assistants are required to abide by HIPAA laws to ensure proper confidentiality when collaborating with patients.

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Therapy Notes vs. Progress Notes

Valant

This covers information such as diagnosis, symptoms, medical history, test results, treatment plan, progress at appointments, prescription medications, etc. They must contain certain information in orderly formatting so other providers and insurance companies can easily use them.

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Reduce patient wait times with these tips

Mobius MD

Does your office staff gather insurance information and patient history when scheduling? An intuitive portal can free up medical staff time by allowing patients to review educational materials, schedule non-urgent appointments, and update their medical histories online.