Which of the following best defines number of diagnoses? a. ...

[itsmyluck]

Which of the following best defines number of diagnoses?
 
  a. Documentation that reflects the physician's familiarity or unfamiliarity with the patient's presenting problem
  b. Documentation of any existing or initiated method of treatment, care, or management of the presenting problem; could range from getting a little rest, to having an invasive medical procedure
  c. Documentation that reflects the physician's specific findings during the E/M service visit with the patient
  d. Documentation of any ordered or requested diagnostic testing to identify the final diagnosis

Question 2

Which of the following excerpts best documents a management option in this medical documentation?
 
  a. Contacted patient's primary physician in Charleston, Texas, by phone to discuss pt's previous hernia surgery, complications, alcohol-related conditions, and health care management related to long history of alcohol use
  b. Patient admitted for overnight observation, IV antibiotics with rehydration
  c. Gastroenterology consultation requested for splenic trauma
  d. All of the above

[smrerig]

Answer to Question 1

a) Documentation that reflects the physician's familiarity or unfamiliarity with the patient's presenting problem

Answer to Question 2

d) All of the above clearly document management options including sought advice, initiation of treatment, and requested consultation