ACDIS CCDS-O Practice Questions - Certified Clinical Documentation Specialist - Outpatient Exam

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In a physician practice, which clinician documentation is typically the basis for diagnosis code assignment in the outpatient setting?

The treating provider's progress note and assessment/plan The nursing intake vitals only The lab requisition form alone The patient's self-reported medical history form

Correct Answer:

The treating provider's progress note and assessment/plan

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