Documentation Standards Flashcards
7 cards from real CAC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation Standards flashcards as text
Under HIPAA, which document must a covered acupuncture practice give to new patients to explain how their health information may be used?
Answer: Notice of Privacy Practices
HIPAA requires covered entities to give patients a Notice of Privacy Practices.
Before treating a 15-year-old patient, whose informed consent is generally required?
Answer: A parent or legal guardian
Minors usually cannot give legal consent, so a parent or guardian must consent, and the patient's assent is also good practice.
Which item should a written informed consent form for acupuncture include?
Answer: Common risks such as bruising, soreness, and minor bleeding
Informed consent means disclosing the material risks, benefits, and alternatives of treatment.
Moxibustion causes a small blister on a patient's skin. What is the best documentation practice?
Answer: Record the location, size, care given, and patient instructions
Every burn or injury needs an objective, complete record of what happened and what care was provided.
Which CPT code describes the initial 15 minutes of personal one-on-one contact for acupuncture without electrical stimulation?
Answer: 97810
CPT 97810 covers the initial 15 minutes of acupuncture without electrical stimulation.
What does the Assessment section of an acupuncture SOAP note usually contain?
Answer: The TCM pattern diagnosis and the practitioner's clinical reasoning
The Assessment section is where the practitioner interprets the findings and states a diagnosis.
Which statement about abbreviations in patient records is most accurate?
Answer: Use only standard, accepted abbreviations, ideally from an approved list
Standard abbreviations prevent misreading by other providers and reviewers.