In a patient's chart, a diagnosis:
A) must be explicitly stated.
B) can be stated or implied.
C) must be part of the HPI.
D) must be coded.

Question

Quizplus · Accepted Answer

A diagnosis can be either explicitly stated or implied within a patient's chart. It does not always have to be directly stated, as healthcare professionals can infer the diagnosis from the patient's history, symptoms, and test results.

In a Patient's Chart, a Diagnosis