CCA Exam Domain 3
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
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
