Identification should include
- verification with two unique identifiers (e.g., date of birth, last four digits of Social Security number)
- chief complaint (e.g., date, time, and signs and symptoms)
- basic information regarding the visit (e.g., duration of signs and symptoms, home treatment)
- signature and title of medical assistant.
Process/Skill Questions:
- What is the importance of accurate documentation?
- What are the consequences of omitting this information?
- Why is it important to verify patient data at each visit?