American Health Information Management Association (AHIMA) Certification Practice Exam

Which report is the best source for determining the size of a removed malignant lesion?

1. Pathology report

2. Post-acute care unit record

3. Operative report

4. Physical examination

The correct answer is: Operative report

The most reliable source for determining the size of a removed malignant lesion is the operative report. This document provides a detailed account of the surgical procedure, including specifics about the lesion's characteristics, the technique used to excise it, and pertinent measurements taken during the operation. In an operative report, surgeons typically record the size of the lesion prior to and after removal, along with any visual observations or photographs that may further illustrate the specimen's dimensions. This information is crucial for understanding the extent of the malignancy and for staging the cancer, which influences treatment plans and prognostic assessments. The pathology report, while containing vital details about the lesion's microscopic examination and diagnosis, might not always include precise size measurements in the same way the operative report does. The post-acute care unit record focuses more on the patient's recovery and care post-surgery rather than the details of the surgical procedure itself. Similarly, the physical examination serves more as an initial assessment tool and does not provide the comprehensive surgical context necessary for accurate size determination. Therefore, the operative report is the best source for this specific information regarding the size of a removed malignant lesion.