Question

A patient presents to the outpatient department for a chest x-ray and sputum culture. The patient was referred from his primary care physician for a long-term cough. The resident physician provides the initial interpretation of the x-ray film and states "pneumonia" and signs the report. Seven days later the sputum culture indicates a streptococcal infection. Which of the following actions should the medical office assistant take?

A. Have the resident physician sign the original note and make an internal change within the medical record.
B. Create a new medical narrative that would take the place of the original, along with an addendum.
C. Allow the note to stand because documentation continuity allows for effective treatment of the patient.
D. Create an addendum because the new information must be connected to the original note.

Answer 1

The medical office assistant should create an addendum connecting the new information about the streptococcal infection to the original note.

Step-by-step explanation:

The medical office assistant should choose option D: Create an addendum because the new information must be connected to the original note.

When the sputum culture indicates a streptococcal infection, it is important to update the patient's medical record with this new information. Creating an addendum allows for accurate documentation and ensures that all relevant information is connected to the original note. This is crucial for providing effective treatment and continuity of care for the patient.

By creating an addendum, the medical office assistant can maintain the integrity of the original note while including the updated information about the streptococcal infection. This provides a complete and accurate picture of the patient's condition and allows for appropriate treatment decisions to be made.

Answer 2

The medical office assistant should create an addendum to the medical record documenting the new streptococcal infection findings, ensuring they are connected with the original pneumonia diagnosis.

Step-by-step explanation:

When a patient presents with a long-term cough and subsequent investigations such as a chest x-ray and sputum culture suggest pneumonia that is later identified as being caused by a streptococcal infection, it is important to document all findings accurately in the medical record. The action the medical office assistant should take is to create an addendum because the new information regarding the streptococcal infection must be connected to the original note without altering the original content. This ensures that transparency is maintained within the patient's medical record and that anyone reviewing the record is aware of the evolution of the patient's diagnosis and treatment.