Which of the following best reflects the documentation of contacted patient's primary physician in Charleston, Texas, by phone to discuss pt's previous hernia surgery?
a. Collection of additional history from patient's family, caretaker, or other source
b. The physician's review of the results of any diagnostic service intended to assist in diagnosing the patient's presenting problem
c. The ordering, planning, or scheduling of any diagnostic service intended to assist in diagnosing the patient's presenting problem
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 abdominal CT scan was reviewed with radiologist; scan showed a small amount of free fluid?
a. Collection of additional history from patient's family, caretaker, or other source
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
Documenting the health history is a crucial step in providing patient care
Stained section of cerebral cortex from autopsy of a patient with Creutzfeldt-Jakob disease
Building competency in patient centered care
Handwritten documentation.
A patient undergoing hemodialysis.
A Mono-Diff test in which the presumptive well contains the patient's serum mixed with ...