American Health Information Management Association (AHIMA) Certification Practice Exam

What documentation is essential for a consultation report in a patient's health record?

1. Insurance information

2. Specialist's findings and recommendations

3. Previous medical history

4. Patient's demographic information

The correct answer is: Specialist's findings and recommendations

The essential documentation for a consultation report in a patient's health record primarily includes the specialist's findings and recommendations. This is crucial because a consultation report is meant to provide an evaluation of the patient’s condition by a specialist who is offering their expert opinion based on the information presented during the consultation. The findings detail the specialist's examination and any tests conducted, while the recommendations outline the proposed plan for treatment or further investigation. Having this information documented ensures continuity of care, enabling other healthcare providers to understand the specialist's perspective and to make informed decisions regarding the patient’s ongoing treatment. While previous medical history, patient demographics, and insurance information are valuable for overall patient management and administrative purposes, they do not directly represent the critical analysis and suggested action steps that are the core of what makes a consultation report valuable in a clinical context.