Which of the following best reflects the documentation of ...

[bclement10]

Which of the following best reflects the documentation of hemoglobin 13.5, WBC: 18,000?
 
  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

Question 2

Which of the following statements best reflects a rule out diagnosis?
 
  a. It is the final diagnosis identified through careful consideration, discernment, and clinical judgment
  b. It is considered to be an uncertain likelihood, but one that could be the final diagnosis
  c. It is intended to either prove that a specific diagnosis is the definitive diagnosis through diagnostic testing, data, and findings, or dismiss that specific diagnosis from any future consideration as the final diagnosis of the presenting problem
  d. It is considered to be very plausible by the physician because of the findings, data, and information gathered about the presenting problem and the patient

[cadimas]

Answer to Question 1

a) The ordering, planning, or scheduling of any diagnostic service intended to assist in diagnosing the patient's presenting problem

Answer to Question 2

c) It is intended to either prove that a specific diagnosis is the definitive diagnosis through diagnostic testing, data, and findings, or dismiss that specific diagnosis from any future consideration as the final diagnosis of the presenting problem

[bclement10]

TYSM

[ebonylittles]

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