Question

Where should you document the following statement from a doctor in the EMR? "Limited abdominal ultrasound showing mild sludge in the gallbladder, without evidence for cholelithiasis or acute cholecystitis. Mild prominence of the common bile duct. Stable since 7/27/2007."

Option 1: Diagnostic Imaging
Option 2: Surgical History
Option 3: Progress Notes

Answer 1

The statement from the doctor about the ultrasound results should be documented in the EMR under the Diagnostic Imaging section, as this is the appropriate area for information derived from imaging studies.

Step-by-step explanation:

The statement from a doctor regarding the results of an ultrasound should be documented in the Electronic Medical Record (EMR) under the Diagnostic Imaging section. This section is specifically designated for imaging studies such as ultrasounds, CT scans, X-rays, and MRI results. The statement includes important diagnostic information, such as the presence of mild sludge in the gallbladder, a mild prominence of the common bile duct, and the absence of conditions like cholelithiasis (gallstones) or acute cholecystitis (inflammation of the gallbladder). Including this information under Diagnostic Imaging would allow healthcare providers to easily access the patient's imaging history for ongoing assessment and treatment planning.