The diagnosis that documents the condition or disease for which the patient is seeking treatment is the:
A) discharge diagnosis
B) final diagnosis
C) provisional diagnosis
D) preoperative diagnosis
Question 2
Which statement regarding the patient record is true?
A) All entries must be legible and complete.
B) An alias cannot be used in a patient record.
C) Only the front page of a two-page document must contain patient identification.
D) The author of each entry does not have to sign the note if another supervising professional has signed it.
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