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•	Documentation and record keeping (62)

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Documentation and record keeping

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1.	Medical Record Retention (2007) American Academy of Pediatrics This article provides resources that can help you determine when it is acceptable to dispose of medical records. Sign in or join AAP to view this type of content.

Setting Up a Computer System (2009)
American Academy of Pediatrics
As you set up your practice, an integral part of your business operations may involve purchasing and implementing a computer system for practice management and electronic records. (From the Launching Your Career in Pediatrics Handbook.)
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Chapter 7: Documenting Telephone Care (2008)
Section on Telephone Care
Provides the background for appropriate documentation for telephone care. Several sample documents are provided. This is part of the AAP's Payment for Telephone Care: A Toolkit.
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Copying Medical Records (2008)
AAP Section on Administration and Practice Management Listserv
This document was created as a result of a Section on Administration and Practice Management e-mail list conversation about providing families with copies of medical records, even if they have an outstanding balance.
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5.	Tamper-Resistant Prescription Pad FAQs (2008) National Council for Prescription Drug Programs This article provides some common questions and answers regarding tamper-resistant prescription pads.

6.	Tamper-Resistant Prescription Pad Security Features Required by States Prior to April 1, 2008 (2008) National Council for Prescription Drug Programs This article provides an overview of the tamper-resistant prescription pad security features that were required by states before April 1, 2008.

Tamper-Resistant Prescription Pads: Requirements From the Centers for Medicare & Medicaid Services (2008)
National Council for Prescription Drug Programs
Beginning April 1, 2008, it will be required that all Medicaid prescriptions be written on a tamper-resistant pad. On October 1, 2008, prescriptions will be required to have a minimum of 1 feature from all 3 Centers for Medicare & Medicaid Services (CMS) categories of tamper-resistant features. This article provides an overview of those requirements.

Tool K: Sample Telephone Documentation Form Version 1 (2008)
Section on Telephone Care
This sample document can be used to note telephone visits and guide the pediatrician on how to charge for the visit. This is part of the AAP's Payment for Telephone Care: A Toolkit.
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Tool L: Sample Telephone Documentation Form Version 2 (2008)
Section on Telephone Care
This sample document can be used to note telephone visits and guide the pediatrician on how to charge for the visit. This is part of the AAP's Payment for Telephone Care: A Toolkit.
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10.

Tool M: Sample Care Plan Oversight Documentation Version 1 (2008)
Section on Telephone Care
This sample document can be used to chart care oversight and length of time provided. This is part of the AAP's Payment for Telephone Care: A Toolkit.
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11.

Tool N: Sample Care Plan Oversight Documentation Version 2 (2008)
Section on Telephone Care
This sample document can be used to chart care oversight and length of time provided. This is part of the AAP's Payment for Telephone Care: A Toolkit.
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12.

ABCs of Clinical Data (2007)
Mark Foster, MD, FAAP and Dianne Koval, MHSA, RHIA
This Fall 2007 SOAPM News article provides an overview of transmitting electronic health information and what standards to look for before purchasing a system.
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13.

Asthma Visit Form (2007)
Jim Stout, MD, MPH, FAAP
This sample form can be used when caring for children who have asthma.

14.

Care Coordination Request Form (2007)
Jennifer Lail, MD, FAAP
This sample form is used by the pediatrician to request care coordination.

15.

Documentation (Starter Kit for Community Preceptors) (2007)
Stanley Fisch, MD, FAAP
Provides information about documentation of the work the student or resident does while working with the community preceptor.

16.

Pre-Visit Contact Form (2007)
Jennifer Lail, MD, FAAP
This sample form can be filled out by parents in preparation for their child's next office visit.

17.

Registration Form for Patients With Special Health Care Needs (2007)
Jennifer Lail, MD, FAAP
This sample form can be used to register a patient who has special health care needs. The form can be adapted as needed.

18.

Sick Visit Sample (2007)
Chestnut Ridge Pediatric Associates, PA
This sample document can be used as a template for sick child visits.
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19.

Well-Child Visit Form Sample #1 (2007)
Chestnut Ridge Pediatric Associates, PA
This sample document can be used for well-child visits.
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20.

Well-Child Visit Form Sample #2 (2007)
Chestnut Ridge Pediatric Associates, PA
This sample document can be used for well-child visits.
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