American Health Information Management Association (AHIMA) Certification Practice Exam

Which report includes a microscopic description of tissue excised during surgery?

1. Recovery room record

2. Pathology report

3. Operative report

4. Discharge summary

The correct answer is: Pathology report

The pathology report is the document that includes a microscopic description of tissue excised during surgery. This report is generated by a pathologist after examining the tissue samples obtained during surgical procedures. It provides crucial information about the cellular characteristics of the tissue, including any abnormalities, such as the presence of cancer or other pathological conditions. This detailed analysis helps guide further treatment and clinical decision-making. The other reports, such as the recovery room record, operative report, and discharge summary, focus on different aspects of patient care. The recovery room record documents the patient's condition and vital signs post-surgery, the operative report details the surgical procedure itself, including techniques used and any complications encountered, while the discharge summary summarizes the patient's hospital stay, diagnosis, and follow-up care plans. None of these documents provide the specific microscopic analysis found in the pathology report.