The content of a legal medical record must be defined in facility ____________________ and standards for maintaining the security and integrity of the information

All of the following are common clues that a child is being neglected EXCEPT:

a. severe diaper rash. b. malnutrition and underweight condition. c. a child patient ignoring and avoiding physical contact with EMS provider. d. untreated medical conditions.

When should a coder query the physician?

A. When the supporting documentation is in the progress note B. When the chart is missing C. When there is unclear or missing information necessary to code an encounter D. When the chart has been updated