Which of the following best reflects the documentation pertinent patient medical records to be reviewed upon receipt by fax?
a. The physician's review of the results of any diagnostic service intended to assist in diagnosing the patient's presenting problem
b. The ordering, planning, or scheduling of any diagnostic service intended to assist in diagnosing the patient's presenting problem
c. Requesting or obtaining the patient's old medical records
d. Discussion of the results of a diagnostic test with the physician who performed that specific diagnostic test
Question 2
Which of the following best reflects the documentation of independent visualization of KUB reveals evidence of significant amount of stool within sigmoid and rectum?
a. The ordering, planning, or scheduling of any diagnostic service intended to assist in diagnosing the patient's presenting problem
b. Requesting or obtaining the patient's old medical records
c. Discussion of the results of a diagnostic test with the physician who performed that specific diagnostic test
d. The personal, independent visualization of the radiologic image, tracing, or scan by the physician who is performing the E/M service visit
Example of variance documentation
Effects of nursing rounds on patient safety
Medical assistants can quickly pull up a patient record when a phone call is received.
Inspecting a patient’s ear during a physical examination.
Walkers help the patient ambulate safely.