CCA Exam Domain 3 Questions and Answers 2023
Which of the following elements is not a component of mos patient records A. Patient identification
B Clinical history
C. Financial information
D. Test results - Answer- Financial information
Identify where the following information would be found in an acute care record: Following induction of an adequate general anesthesia, and with the patient supine on the padded table, the left upper extremity was prepped and draped in the standard fashion
A. Anesthesia report
B. Physician progress notes
C. Operative Report D. Recovery room record - Answer- Operative report
Identify where the following information would be found in the acute care record CBC, WBC 12.0, RBC 4.65, HGB 14.8, MCV 93?
A. Medical laboratory report
B. Pathology report
C. Physical examination
D. Physician orders - Answer- Pathology report
Identify where the following information would be found in the acute care record: PA and
lateral chest, the lungs are clear. The heart and mediastinum are normal in size and configuration. There are minor degenerative changes of the lower thoracic spine.
A. Medical laboratory report
B. Physical examination
C. Physician progress note D. Radiography report - Answer- Radiography report
The____ provided the impetus for standardizing health care records with minimum standards early in the twentieth centry? - Answer- ACS
The following is documented in an acute care record. Microscopic sections are of squamous mucous with no atypia. Where would this documentation be found? A. History
B. Pathology report
C. Physical Examination
D. Operative Report - Answer- Pathology report The following is documented in an acute-care record: "Admit to 3C. Diet: NPO. Meds: Compazine 10 mg IV Q 6 PRN." In which of the following would this documentation appear?
a. Admission order
b. History
c. Physical examination
d. Progress notes - Answer- Admission order
The following is documented in an acute care record: 38 weeks of gestation, Apgars 8/9. 6# 9.8oz, good cry. Where would this documentation be found?
A. Admission note
B. Clinical laboratory
C. Newborn record
D. Physician order - Answer- Newborn record
The following is documented in an acute care record: Atrial fibriliation with rapid ventricular response, left axis deviation, left bundle branch block. Where would this documentation be found?
A. Admission order
B. Clinical laboratory report
C. ECG report
D. Radiology report - Answer- ECG report
The regulation for health care record content and documentaion, guidelines and regulations for which facilities are allowed to take part or join the Medicare and Medicaid
programs is? A. Medical staff bylaws
B Conditions of participation C. Joint commission rules D. American college of surgeon regulations - Answer- Conditions of participation
The following is documented in an acute care record: Spoke to the attending, my assessment provided adoption and counseling information. Spoke to CPS referral. Case
manager to meet with patient of family. Where would this documentation be found?
A. Admission note
B. Nursing note
C. Physician progress note
D. Social work note - Answer- Social work note
Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of a patient to the acute care hospital in which she works. The first resource that she should use is ______.
Which of the following elements is not a component of mos patient records A. Patient identification
B Clinical history
C. Financial information
D. Test results - Answer- Financial information
Identify where the following information would be found in an acute care record: Following induction of an adequate general anesthesia, and with the patient supine on the padded table, the left upper extremity was prepped and draped in the standard fashion
A. Anesthesia report
B. Physician progress notes
C. Operative Report D. Recovery room record - Answer- Operative report
Identify where the following information would be found in the acute care record CBC, WBC 12.0, RBC 4.65, HGB 14.8, MCV 93?
A. Medical laboratory report
B. Pathology report
C. Physical examination
D. Physician orders - Answer- Pathology report
Identify where the following information would be found in the acute care record: PA and
lateral chest, the lungs are clear. The heart and mediastinum are normal in size and configuration. There are minor degenerative changes of the lower thoracic spine.
A. Medical laboratory report
B. Physical examination
C. Physician progress note D. Radiography report - Answer- Radiography report
The____ provided the impetus for standardizing health care records with minimum standards early in the twentieth centry? - Answer- ACS
The following is documented in an acute care record. Microscopic sections are of squamous mucous with no atypia. Where would this documentation be found? A. History
B. Pathology report
C. Physical Examination
D. Operative Report - Answer- Pathology report The following is documented in an acute-care record: "Admit to 3C. Diet: NPO. Meds: Compazine 10 mg IV Q 6 PRN." In which of the following would this documentation appear?
a. Admission order
b. History
c. Physical examination
d. Progress notes - Answer- Admission order
The following is documented in an acute care record: 38 weeks of gestation, Apgars 8/9. 6# 9.8oz, good cry. Where would this documentation be found?
A. Admission note
B. Clinical laboratory
C. Newborn record
D. Physician order - Answer- Newborn record
The following is documented in an acute care record: Atrial fibriliation with rapid ventricular response, left axis deviation, left bundle branch block. Where would this documentation be found?
A. Admission order
B. Clinical laboratory report
C. ECG report
D. Radiology report - Answer- ECG report
The regulation for health care record content and documentaion, guidelines and regulations for which facilities are allowed to take part or join the Medicare and Medicaid
programs is? A. Medical staff bylaws
B Conditions of participation C. Joint commission rules D. American college of surgeon regulations - Answer- Conditions of participation
The following is documented in an acute care record: Spoke to the attending, my assessment provided adoption and counseling information. Spoke to CPS referral. Case
manager to meet with patient of family. Where would this documentation be found?
A. Admission note
B. Nursing note
C. Physician progress note
D. Social work note - Answer- Social work note
Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of a patient to the acute care hospital in which she works. The first resource that she should use is ______.
