Diagnostic Report

Diagnostic reports do not need to be written in a structured format.

• True

• False

A patient complains of fatigue. The provider orders a complete blood count (CBC), which shows a low red blood cell count. What is the purpose of including the CBC result in the diagnostic report?

• To explain the billing process

• To document the provider’s opinion

• To provide objective evidence supporting the diagnosis

• To list medications the patient is currently taking

Which items are appropriate for a medical report summarizing a patient's condition, treatment, and follow-up care, such as in a discharge summary after the patient underwent surgery?

• A. Pain medication given

• B. Physical therapy schedule

• C. Result of X-ray

• D. Nurse’s post-operation instructions

• E. Family contact number

What makes a report high-quality and professional?

• Relevant information

• Slang and shorthand for speed

• Follow a chronological order

• Accurately stating facts

• Use of standard terminology

A SOAP note is typically used for which of the following purposes?

• Documenting patient encounters

• Scheduling appointments

• Billing insurance companies

• Ordering laboratory tests