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Discussing Exam Observations After examining your child, I will discuss my findings and the diagnostic impression as well as recommendations for treatment, additional tests, or evaluation by other physicians if needed. This is documented as medical decision-making and includes the diagnosis with its status (acute, chronic, stable, exacerbated), immediate assessment and plan, ordering lab or radiologic tests if necessary, review of additional data such as past exam reports and/or tests (blood chemistry or hematology, CT, MRI scans), and a level of risk based upon these findings. I will encourage you to ask questions, and you are always welcome to call later if the information is difficult to assimilate while you are in the office. |