Question

Which foot? You received a Request for Examination to provide clinical evidence for a specific condition that affects Mr. A. Smith's right foot. As Mr. Smith walks to the examination table, he limps to avoid putting weight on his left foot. When you interview Mr. Smith for his history, Mr. Smith insists that his problem is with his left foot. What should be your next step? Select the best course of action from the following four options.

A.Assume there was a typographical error in the Request for Examination and assess Mr. Smith's left foot.
B.Immediately call the contact information given on the bottom of the Request for Examination for clarification.
C.Close the examination. Apologize to Mr. Smith and explain to him that his exam will be rescheduled when the correct foot to be examined has been determined.
D.Examine both feet. It's likely that both feet will need to be examined before the claim is adjudicated.

Answer 1

When faced with inconsistent information regarding a patient's condition, contacting the issuer of the examination request for clarification is the appropriate action to ensure correct diagnosis and care.

Step-by-step explanation:

The correct course of action when observing a discrepancy between the Request for Examination and the patient's reported symptoms would be option B: Immediately call the contact information given on the bottom of the Request for Examination for clarification.

This is to ensure that you are looking into the right condition and that the records correspond with the patient's actual medical issues. It's imperative to maintain accuracy in medical documentation and examinations, not only for the patient's health but also for legal and insurance reasons. Assessing the wrong body part could result in a misdiagnosis or a missed diagnosis altogether.

In patient examinations, careful attention to clinical history and symptoms is essential. For instance, in the excerpts provided, patients displayed various symptoms that guided healthcare professionals towards specific tests and treatments. From indications of a potential embolus to sensory system impairments, each symptom informed the next steps in patient care.