American Health Information Management Association (AHIMA) Certification Practice Exam

Which section of a medical record provides information about diseases among relatives?

1. Physical examination

2. History

3. Laboratory report

4. Administrative data

The correct answer is: History

The section of a medical record that provides information about diseases among relatives is the history section. This part of the record typically includes the patient's medical history, family history, social history, and any pertinent information that could impact the patient's health or treatment. In the context of family history, it specifically focuses on genetic or hereditary conditions that may affect the patient. Understanding the health issues that relatives have faced is crucial for identifying potential risks for the patient, guiding appropriate preventive measures, or tailoring treatments based on genetic predispositions. The physical examination mainly documents the current physical state of the patient rather than family health history. Laboratory reports focus on the results of tests conducted to assess the patient's health rather than demographic or familial background. Administrative data generally includes non-clinical information such as patient identification and billing details, which do not pertain to the patient's or their family's health history. Therefore, the history section is the appropriate source for relevant familial disease information.