Registered Health Information Administrator (RHIA) — Question 67

In preparation for an HER, you are conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is

Answer options

• A. recovery room record.
• B. pathology report.
• C. operative report.
• D. discharge summary.

Correct answer: B

Explanation

The correct answer is B, pathology report, as it specifically documents the findings related to the tissue examined post-surgery. The other options do not pertain to the microscopic analysis of excised tissue; A refers to post-anesthesia recovery, C details the surgical procedure performed, and D summarizes the patient's hospital stay upon discharge.