If the condition of a patient is being clinically evaluated, the coder would expect to see ____.
A)an admission date
B)letters
C)clinical observations
D)an operative report

Question

Quizplus · Accepted Answer

When a patient is being clinically evaluated, the coder would expect to see clinical observations being recorded in the patient's medical record. These observations may include vital signs, physical examination findings, medical history, and laboratory test results. The other options, such as an admission date, letters, or an operative report, may or may not be relevant to the clinical evaluation depending on the specific circumstances.

If the Condition of a Patient Is Being Clinically Evaluated