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Chart Audit and Review Form

Chart Number/Name: Comments: Overall Appearance of Chart Chart Organization Chart Contents Dated Entry documented Patient's Initial Exam Chief complaint/initial assessment Medical History (current & past) Family History (current & past) Physical Exam Screening for problems Allergies/alerts (up-to-date?) Medications and dosage (dates) Progress Notes Physician/Provider signature Date/vital signs Medications Problem Management Abnormal findings Continuity of Physician Referrals Special Documentation Procedure Consent for in-office services Consent of out-of-office services Consultant Notes Hospital Documentation Other Assignment of benefits/copy of Insurance card Release of information Medical necessity waiver form Receipt of Notice of Privacy Practice Y/ N Date:

Good / Fair / Poor Good / Fair / Poor If no, give Reason

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Chart Audit and Review Form

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