For inpatients, the first data item collected of a clinical nature is usually
A. principal diagnosis. C. admitting diagnosis.
B. expected payer. D. review of systems.
C Clinical data include all health care information collected during a patient's episode of care.
During the registration or intake process, the admitting diagnosis, provided by the attending
physician, is entered on the face sheet. If the patient is admitted through the ED, the chief
complaint listed on the ED record is usually the first clinical data collected. The principal
diagnosis is often not known until after diagnostic tests are conducted. Demographic data are
not clinical in nature. The review of systems is collected during the history and physical,
which is typically done after admission to the hospital.
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