What should an auditor expect to see when reviewing old records?

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When reviewing old records, it is often expected that there will be a summary of findings based on discussions with the physician. This summary provides a concise overview of the patient's medical history and the clinician's assessment, which can help auditors understand the rationale behind specific treatments and decisions made over time. This type of documentation is particularly valuable for evaluating the continuity of care and the clinical reasoning applied throughout the patient's treatment history.

While it is important for records to include a variety of information, such as treatment documentation, test results, and demographic data, creating summaries allows for efficient retrieval of essential clinical insights. It effectively highlights significant aspects of the patient care which may not be as readily apparent in complete records or raw data. This accessibility is crucial for auditors who analyze patterns, assess compliance with coding standards, and evaluate the appropriateness of care without sifting through potentially extensive and detailed historical documents.

Thus, option B aligns with the practical needs of auditors in interpreting a patient's medical journey through a lens that emphasizes clinical discourse and evaluation.

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