American Health Information Management Association (AHIMA) Certification Practice Exam

What type of report does a specialist use to document their opinion after evaluating a patient?

1. Consultation

2. Medical history

3. Physical examination

4. Progress notes

The correct answer is: Consultation

A consultation report is specifically designed for specialists to document their findings and opinions after evaluating a patient. When a specialist is called in to assess a patient's condition or provide expertise beyond the primary care provider's scope, they generate a consultation report. This document captures the purpose of the consultation, the details of the evaluation, the specialist's diagnostic impression, and any recommendations for further management or treatment. It is an essential part of the medical record that helps ensure continuity of care and communication among healthcare providers. In contrast, medical history documents a patient's past health events, physical examinations record the results of a hands-on assessment, and progress notes track a patient's ongoing treatment and response over time. While these documents are also significant in a patient's medical record, they do not specifically serve the purpose of presenting an opinion arising from a specialized evaluation.