When documenting a new encounter, which of the following would be the next step after locating the patient, setting the time and date, and clicking OK?

A) Record the patient's chief complaint.
B) Record the patient's symptoms.
C) Record the patient's vital signs.
D) Record the patient's diagnosis as made by the clinician.


A

Health Professions

You might also like to view...

A 9-year-old with a history of congenital heart disease is in cardiac arrest. What instruction would you give other EMTs on scene?

A) "Let's use the adult pads and adult settings for the AED." B) "Just do CPR until ALS arrives since we do not know the specific heart condition." C) "Remember that for pediatrics, it is 2 shocks followed by 2 minutes of CPR." D) "We will need the special pediatric pads for this pediatric patient."

Health Professions

Which equipment will not be required to obtain information about the admission of a new resident?

A. Thermometer B. Stethoscope C. Sphygmomanometer D. Tongue depressor

Health Professions

The amount that insured individuals have to pay out of pocket before insurance begins paying is called the ________.

Fill in the blank(s) with the appropriate word(s).

Health Professions

When conducting a documentation compliance audit, consultants typically review every record of every patient treated during the previous month

Indicate whether the statement is true or false

Health Professions