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Registered Health Information Administrator (RHIA) Questions 736–740 (page: 149)

A patient was admitted with severe abdominal pain, elevated temperature, and nausea. The physical examination indicated possible cholecystitis. Acute and chronic pancreatitis secondary to alcoholism was recorded on the face sheet as the final diagnosis. The principal diagnosis is

The physician explicitly documents that a condition is not present at the time of admission.

The physician documents that the patient has diabetes that was diagnosed prior to admission.

The medical record documentation is unclear as to whether the condition was present on admission.

Patient is admitted to the hospital with acute abdominal pain. The attending medical physician requests a surgical consult. The consultant agrees to see the patient and conducts a comprehensive history and physical examination. The physician ordered lab work to rule out pancreatitis, along with an ultrasound of the gallbladder and abdominal x-ray. Due to the various diagnosis possibilities and the tests reviewed, a moderate medical decision was made.