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Question:
When the technique of a nuclear medicine exam states that a whole-body exam was performed, must the doctor document each area of the body, or may the doctor dictate any issues found and then state “remainder of whole-body scan was unremarkable”?
Answer:
Yes, that is sufficient documentation. The doctor should document positive findings, pertinent negatives, and then a comment such as “remainder of whole-body scan unremarkable.”
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