A clinician has just created an annotated drawing in a patient's EHR. The drawing depicts the location of a mole on the patient's back, and the annotation indicates that the mole is 1.1 cm wide. In this scenario,
A) the clinician will also need to document the mole's size as a finding in the encounter note.
B) information regarding the mole's size will automatically be added to the encounter note as codified data.
C) the clinician will need to generate a PDF of the annotated drawing and attach it to the electronic encounter.
D) the image depicting the mole's location will not become part of the electronic encounter.
Question 2
You have a job in the HIM department. A friend of yours works for a lawyer. She comes to your facility to pick up copies of records for one of her boss's clients. She has forgotten to bring the client's authorization form.
She is in a hurry and doesn't have time to go back to her office. You have known her for many years and are good friends. Do you give her the records without the authorization form?
(A) Scratch test; patient is exposed to allergens through a light scratch on the skin; (B) Positive
Cervical plexus drawing
Inspecting a patient’s ear during a physical examination.
Clinician performing capillary refill assessment.
Erosional Landforms Created by Alpine Glaciers