When documenting the exam, the provider may notate "normal" or "unchanged" for the body area or organ systems that are normal. Elaboration on _______________ is required.

A. Unremarkable, Routine
B. Normal, Unchanged
C. Negative, Stable
D. Healthy, Consistent findings

Answer :

Final answer:

In medical documentation, 'Normal, Unchanged' notations are used for areas that show no abnormalities, while a detailed description is required for any deviations from this standard state.

Explanation:

When documenting a patient's exam, providers may use notation such as "Normal," "Unchanged" to indicate that the examined body area or organ systems appear usual and do not show any abnormal findings. However, elaboration is required on findings that are not part of the routine unchecked status. This means that if there are any abnormal findings or changes in the patient's condition, detailed descriptions should be provided in the medical record. The correct option here is "B. Normal, Unchanged", as this choice best fits the standard practices in medical documentation for what appears to be satisfactory without any new or concerning changes from the previous state.