A clinician has just created an annotated drawing in a patient's EHR. The drawing depicts the location of a mole on the patient's back, and the annotation indicates that the mole is 1.1 cm wide. In this scenario,
A) the clinician will also need to document the mole's size as a finding in the encounter note.
B) information regarding the mole's size will automatically be added to the encounter note as codified data.
C) the clinician will need to generate a PDF of the annotated drawing and attach it to the electronic encounter.
D) the image depicting the mole's location will not become part of the electronic encounter.
Question 2
You have a job in the HIM department. A friend of yours works for a lawyer. She comes to your facility to pick up copies of records for one of her boss's clients. She has forgotten to bring the client's authorization form.
She is in a hurry and doesn't have time to go back to her office. You have known her for many years and are good friends. Do you give her the records without the authorization form?
Nurses possess a wide variety of experiences which they take into each patient encounter.
Photograph of an occupational therapist assisting a patient with learning independence in activities
A patient undergoing hemodialysis.
Christmas kids drawing
Eater kids drawing
Father’s Day kid drawing kindergarten