Medicare Risk Adjustment Tip: Review of Systems and Exam Diagnosis Support

A review of the system is decided by the main complaint. All documentation must be complete and based on examination from a specific encounter with the patient. The physical examination continues the diagnostic process, combining information obtained by inspection, palpation, percussion, and auscultation. Getting the correct diagnosis is a key aspect of health care – it provides an explanation of the patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves gathering clinical logic and information to determine a patient's health problem.


 

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