American Health Information Management Association (AHIMA) Certification Practice Exam

According to the Joint Commission, what document is required before performing a surgical procedure?

1. Admission record

2. Physician's order

3. Report of history and physical examination

4. Discharge summary

The correct answer is: Report of history and physical examination

The requirement for a report of history and physical examination prior to performing a surgical procedure is rooted in the need for comprehensive patient assessment and safety. This document provides crucial information about the patient's medical history, current health status, and any relevant physical examination findings that could influence the surgical approach and planning. By reviewing the patient's health history, the surgical team can identify any potential risks or contraindications to the procedure, ensuring that the appropriate precautions are taken. Having an admission record, physician's order, and discharge summary are important components of the patient's overall medical care but are not specifically mandated by the Joint Commission as prerequisites for surgery. The admission record relates to the patient's entry into the healthcare system, physician's orders detail the specific treatments or interventions prescribed, and the discharge summary is created after treatment is completed. None of these documents provide the same level of critical, up-to-date health information as the report of history and physical examination, which is essential for informed decision-making in surgical contexts.