The health care providers at your hospital do a very thorough job of periodic open record review to ensure the completeness of record documentation. A qualitative review of surgical records would likely include checking for documentation regarding
A. the presence or absence of such items as preoperative and postoperative diagnosis, description
of findings, and specimens removed.
B. whether a postoperative infection occurred and how it was treated.
C. the quality of follow-up care.
D. whether the severity of illness and/or intensity of service warranted acute level care.
Answer: A. the presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed.