Registered Health Information Administrator (RHIA) — Question 126

As the Chair of the Forms Committee at your hospital, you are helping to design a template for house staff members to use while collecting information for the history and physical. When asked to explain how "review of systems" differs from "physical exam," you explain that the review of systems is used to document

Answer options

• A. objective symptoms observed by the physician.
• B. past and current activities, such as smoking and drinking habits.
• C. a chronological description of patient’s present condition from time of onset to present.
• D. subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant.

Correct answer: D

Explanation

The correct answer is D because the review of systems focuses on gathering subjective information that the patient might not have initially disclosed. Options A, B, and C represent objective findings or history rather than the subjective symptoms that are the primary focus of the review of systems.