Certified Risk Adjustment Coder (CRC)

Which element of the documentation includes the provider's objective findings?

1. History

2. Exam

3. Assessment

4. Plan

The correct answer is: Exam

The element of documentation that includes the provider's objective findings is the Exam. This section is critical because it encompasses the healthcare provider’s observations and physical examination results, which are crucial for forming a complete understanding of the patient's health status. The objective findings may include vital signs, observable physical signs, and results from diagnostic tests. This differentiation is essential for accurate coding and risk adjustment, as it provides concrete evidence of the patient’s current health condition, which is directly relevant to the coding process. While the History focuses on the patient's reported symptoms and prior conditions, and the Assessment and Plan involve clinical reasoning and future care strategies, it is within the Exam section that you find the measurable and observable data that supports the provider's decision-making.