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In which section of the EMR would you record the physician's interpretation of the patient's labs?

Option 1: Assessment
Option 2: Medication List
Option 3: Laboratory Results
Option 4: Treatment Plan

User JanivZ
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1 Answer

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Final answer:

The physician's interpretation of labs is recorded in the Assessment section of the EMR, where preliminary diagnoses and further test considerations are documented.

Step-by-step explanation:

In the Electronic Medical Record (EMR), the physician's interpretation of the patient's labs is typically recorded in the Assessment section. This section is used to document the clinician's findings and thoughts based on the lab results along with the patient's history, symptoms, and physical exam findings. The Assessment may include a preliminary diagnosis and considerations for further tests or referrals needed for diagnosis clarification. The Medication List contains information about the medications prescribed to the patient including dosage and frequency, whereas the Laboratory Results section is for recording the actual results of lab tests. The Treatment Plan would detail the recommended course of treatment based on the assessment and diagnosis.

User Maxi Schvindt
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