HIT 141 Quizzes Complete Solutions 2024/2025 | Already Passed

Which of the following clinical data elements is NOT usually documented in the acute-care health record? A. Clinical observations B. Medical history C. Immunization records D. Discharge summary - C. Immunization records Results of a urinalysis and all blood tests performed would be found in what part of a healthcare record? A. Autopsy report B. Operative report C. Pathology report D. Laboratory report - D. Laboratory report What is the function of a consultation report? A. Provides a chronological summary of the patient's medical history and illness B. Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care C. Concisely summarizes the patient's treatment and stay in the hospital from the time of admission to the time of discharge D. Documents the patient's instructions to other parties involved in providing care to a patient. - B. Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care