Which of the following documents is usually found only in the problem-oriented medical record?
Medical history
Hospital reports
Problem list
Diagnostic reports
Progress notes
Problem list
Rationale: Because problem-oriented medical records are based on the complaint or illness bringing the patient into the office, the problem list would only be found in this type of record. The others listed would be found typically in source-oriented medical records.
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The chronological recording of pertinent facts and observations regarding a patient's health status is known as:
A) medical transcription. B) documentation. C) claims processing. D) encounter form completion.
Which of the following provides the basis for determining whether an imaging procedure or practice is justified?
a. ALARA concept b. BERT method c. Diagnostic efficacy d. NEXT program