Registered Health Information Administrator (RHIA) — Question 72

You notice on the admission H&P that Mr. McKahan, a Medicare patient, was admitted for disc surgery, but the progress notes indicate that due to some heat irregularities, he many not be a good surgical risk. Because of your knowledge of COP regulations, you expect that a(n)_______________ will be added to his health record

Answer options

• A. interval summary.
• B. consultation report.
• C. advance directive.
• D. interdisciplinary care plan.

Correct answer: B

Explanation

The correct answer is B, as a consultation report is typically required to assess the patient's surgical risk when there are concerns about their health status. The other options do not specifically address the need for a professional opinion on the patient's surgical eligibility, with interval summaries and care plans being more general documentation and advance directives focusing on patient wishes regarding care.