Question

List two sources within a medical record where the information about present or recent illnesses is most likely to be found.

Answer 1

Information about present or recent illnesses can often be found in a medical record's History of Present Illness (HPI) section and the Progress Notes. The HPI details the patient's symptoms and their development, while Progress Notes track the course of the illness and treatments over time. ICD codes play a key role throughout this process.

Step-by-step explanation:

Two sources within a medical record where information about present or recent illnesses is most likely to be found are the History of Present Illness (HPI) section and the Progress Notes. The HPI provides a detailed description, often in a narrative form, of the patient's current complaint and symptoms, how these have developed over time, and the impact on the patient's daily life. Progress Notes document the course of the patient's illness, including observations, treatments administered, and the patient's response to those treatments over the course of their stay in a healthcare setting.

For example, if a patient seeks treatment for a viral infection, they may mention symptoms in the HPI that lead a clinician to suspect a particular virus. The clinician would then likely order laboratory tests and use the International Classification of Diseases (ICD) codes to designate the suspected virus. Observations during treatment, test results, and medications prescribed would be updated regularly in the Progress Notes. ICD codes are crucial in this process and are found in various facets of the health care system, including medical lab work and billing procedures.

Answer 2

The two sources within a medical record where the information about present or recent illnesses is most likely to be found are the lab reports and the physician's order. The medical history and physical examination sections of the medical record should contain information about present illnesses. Other possible sources of information are patient referral letters, the discharge summary, and the operative report.