Registered Health Information Administrator (RHIA) — Question 144

Discharge summary documentation must include

Answer options

• A. a detailed history of the patient.
• B. a note from social services or discharge planning.
• C. significant findings during hospitalization.
• D. correct codes for significant procedures

Correct answer: C

Explanation

The correct answer is C because the discharge summary should highlight significant findings during the patient's hospitalization, which are crucial for continuity of care. Options A and B are important but not mandatory for the discharge summary, while D refers to coding procedures, which, although relevant, is not a primary requirement for the summary itself.