Which of the following is the second most common medical document from which diagnostic statements can be extracted?
A) Encounter form
B) Treatment notes
C) Discharge summary
D) Radiology, laboratory, or pathology report

Question

Quizplus · Accepted Answer

Treatment notes are the second most common medical document from which diagnostic statements can be extracted. The encounter form is most commonly used to obtain the list of medical services rendered and the treating diagnosis when calculating total charges. The discharge summary is used primarily for extracting diagnostic information for patients who were hospitalized rather than seen in the provider's office. Radiology, laboratory, and pathology reports are used to support and/or establish the diagnostic statement.

Which of the Following Is the Second Most Common Medical