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Author Question: How does the diagnostic section of a report (imaging reports and lab values) relate to the ... (Read 51 times)

dollx

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on: Jun 27, 2018
How does the diagnostic section of a report (imaging reports and lab values) relate to the Assessment?
 
  What will be an ideal response?

Question 2

How does the medication list relate to the Past Medical History and why should these sections be free of contradictions?
 
  What will be an ideal response?


Zebsrer

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Reply #1 on: Jun 27, 2018
Answer to Question 1

The diagnostic tests are used to make the assessment (conclusion, diagnosis), so the results of those tests should support the conclusions made by the physician. For example, a negative x-ray would not support a diagnosis of fracture.

Answer to Question 2

The Past Medical History section may include the patient's ongoing (chronic) problems, and often these problems require medications. Significant chronic illnesses such as hypertension, diabetes, autoimmune disorders, and HIV are almost always treated pharmaceutically. A conflict between the patient's current illnesses and medications should alert the transcriptionist to the possibility of an error in one section or the other.


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