Which document contains the physician's findings from an examination?

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 document that contains the physician's findings from an examination is the physical exam. This document serves as a detailed report generated during a patient’s physical examination, outlining the physician's observations, assessments, and findings regarding the patient's current health status. It typically includes information such as vital signs, assessment of various body systems, and any abnormalities noted during the examination.

In contrast, a discharge summary is a document that summarizes the patient's hospital stay, including diagnoses, treatments received, and follow-up care instructions, but it does not focus specifically on the findings from the examination. The medical history records the patient's past medical experiences, health conditions, and family history, which are crucial for understanding a patient’s overall health, but they do not provide real-time data from an examination. Patient instructions generally consist of guidance given to the patient regarding their care after a visit, emphasizing what steps they should take next, rather than clinical findings from an examination.

Subscribe

Get the latest from Examzify

You can unsubscribe at any time. Read our privacy policy