Which of the following best reflects the documented excerpt titled Assessment?
a. A possible diagnosis because the performing physician is not sure how the patient's history of alcoholism has impacted the patient's health
b. A probable diagnosis because the performing physician is requesting records from the previous physician in Texas
c. A definite diagnosis because the performing physician documents the splenic laceration by specific grade based on the radiologic findings
d. A rule out diagnosis because the performing physician has not definitively diagnosed the presenting problem
Question 2
Which of the following best reflects the number of diagnoses for this medical documentation?
a. Established problem, stable or improving
b. Established problem, worsening
c. New problem without diagnostic workup
d. New problem with diagnostic workup
Patients with physical special needs, such as a wheelchair, need to have this documented in their he
Assessment of Skin Turgor
Health Assessment
Assessment by Domain
Assessment of Asthma
Assessment of central venous pressure