American Health Information Management Association (AHIMA) Certification Practice Exam

What method ensures that history and physical examinations are documented within 24 hours of admission?

1. Retrospective review of medical records

2. Concurrent review of medical records

3. Review of records upon discharge

4. Review of records for patients discharged in the last 60 days

The correct answer is: Concurrent review of medical records

The method that ensures history and physical examinations are documented within 24 hours of admission is concurrent review of medical records. This approach involves monitoring and evaluating patient records during the course of care rather than after it has been completed. By utilizing concurrent reviews, healthcare staff can promptly identify whether the necessary documentation has been completed within the required timeframe, thus ensuring compliance with regulatory and accreditation standards. This timely oversight allows for immediate action if documentation is lacking or incomplete, thereby enhancing the quality of patient care and maintaining accurate medical records. In contrast, retrospective review of medical records occurs after patient care has been delivered, focusing on documenting and analyzing prior admissions and care, which does not facilitate timely documentation. Reviewing records upon discharge typically happens after a patient has left the facility, making it ineffective for ensuring timely documentation during admission. Lastly, reviewing records for patients discharged in the last 60 days is retrospective and would also not ensure that history and physical examinations are documented within the specific 24-hour timeframe after admission.