In an acute-care record, documentation describing clear tympanic membranes and good bilateral chest sounds is found in which section?

Prepare for the RHIT Domain 1 Test. Study with flashcards and multiple choice questions with hints and explanations. Get ready for your certification exam!

The section where documentation such as clear tympanic membranes and good bilateral chest sounds would be found is the physical examination. This section is specifically dedicated to the healthcare provider's findings regarding the patient's body upon examination. It includes observations related to various systems, such as the ears, respiratory, and other physical assessments.

During a physical examination, a clinician will assess various aspects of the patient’s health, including vital signs, overall appearance, and specific findings like those mentioned in the question. The documentation reflects the provider's observations and clinical evaluations at that moment in time, making this section the appropriate place for such detailed descriptions concerning the patient's status.

The other options, such as medical history, pathology report, and operation report, do not typically contain real-time findings from a physical examination. The medical history focuses more on the patient's past illnesses, family history, and previous medical events, while pathology reports detail laboratory results and the analysis of tissues, and operation reports document surgical procedures. Hence, the physical examination is the correct context for such observations.

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