Registered Health Information Administrator (RHIA) — Question 28

Joint Commission standards require that a complete history and physical be documented on the health records of operative patients. Does this report carry a time requirement?

Answer options

• A. yes, within 8 hours post-surgery.
• B. no, as long as it is dictated before surgery.
• C. yes, prior to surgery.
• D. yes, within 24 hours post-surgery.

Correct answer: C

Explanation

The correct answer is C, as the Joint Commission standards mandate that a complete history and physical must be documented before surgery. Options A and D suggest time frames after surgery, which do not meet the requirement, while B incorrectly states that dictation before surgery suffices without documentation.