Answer to Question 1
D
The advance directive, which should be located in a special section of the patient's medical record, should be examined first because the patient's symptoms indicate that he may need to be resuscitated. The advance directive contains information about the patient's wishes for intensity of care and actions that should be taken in the event of a life-threatening event. The discharge plan contains data from utilization review, case managers, or discharge planners on anticipated needs after discharge. Graphic data record assessment should be done frequently, such as vital signs. The history and physical examination provide a detailed summary of the patient's current problem, past medical and social history, medications taken by the patient, review of systems, and physical examination data.
Answer to Question 2
C
A single lifestyle change, such as weight loss, can lower blood pressure (BP). Whenever the client has an elevated BP, the reading should be monitored even when it occurs just occasionally. Drinking too much alcohol is associated with hypertension, but water consumption is not unless accompanied by high sodium intake. A diet high in calcium is recommended to prevent and manage hypertension; therefore, it is not advisable to limit the intake of dietary calcium found in dairy products.
CPT Modifiers Used for Medical Office Services
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