Question

A client is admitted to the hospital with a tentative medical diagnosis, and multiple diagnostic tests are performed. Where in the client's medical record can the nurse find documentation about the current medical diagnosis after the diagnostic test results are reviewed by the primary health-care provider?

1. Progress Notes
2. Admission Sheet
3. History and Physical
4. Social Service Record

Answer 1

The current medical diagnosis after diagnostic tests are reviewed by the primary health-care provider can usually be found in the Progress Notes section of the patient's medical record.

Step-by-step explanation:

In a hospital setting, once the primary health-care provider has reviewed the multiple diagnostic test results for a patient, the documentation regarding the current medical diagnosis is typically found in the Progress Notes section of the client's medical record. The Progress Notes provide an ongoing record of the patient's condition and treatment, and are updated by healthcare providers after reviewing test results and making assessments. This would include the diagnostic conclusions made after analyzing the results of tests such as blood screenings, imaging studies, or other evaluations. Additionally, it's important to note that while the diagnosis may initially be documented in the Progress Notes, this information will later be integrated into the patient's full medical history and possibly reflected in other parts of the medical record such as the discharge summary. On the other hand, the Admission Sheet typically contains initial assessments, the History and Physical may contain preliminary diagnoses before tests are conducted, and the Social Service Record generally involves social or psychological factors, not medical diagnoses.