CCS EXAM CORRECT QUESTIONS &
ANSWERS(RATED A+)
For continuity of care, ambulatory care providers are more likely than providers of acute
care services to rely on the documentation found in the
interdisciplinary patient care plan.
discharge summary.
transfer record.For continuity of care, ambulatory care providers are more likely than
providers of acute care services to rely on the documentation found in the
interdisciplinary patient care plan.
problem list.
discharge summary.
transfer record. - ANSWER
Discharge summary documentation must include
correct codes for significant procedures.
a note from social services or discharge planning.
significant findings during hospitalization.
a detailed history of the patient. - ANSWER significant findings during hospitalization.
Some reference to the patient's history may be found in the discharge summary but not
a detailed history. The attending physician rather than a social worker records the
discharge summary. Procedure codes are usually recorded on a different form in the
record.
In preparation for an EHR, you are conducting a total facility inventory of all forms
currently used. You must name each form for bar coding and indexing into a document
management system. The unnamed document in front of you includes a microscopic
description of tissue excised during surgery. The document type you are most likely to
give to this form is
operative report.
discharge summary.
pathology report.
recovery room record. - ANSWER pathology report.
Although a gross description of tissue removed may be mentioned on the operative note
or discharge summary, only the pathology report will contain a microscopic description.
,You have been asked to identify every reportable case of cancer from the previous
year. A key resource will be the facility's
disease index.
physicians' index.
number control index.
patient index. - ANSWER disease index.
The major sources of case findings for cancer registry programs are the pathology
department, the disease index, and the logs of patients treated in radiology and other
outpatient departments. The number index identifies new health record numbers and
the patients to whom they were assigned. The physicians' index identifies all patients
treated by each doctor. The patient index links each patient treated in a facility with the
health number under which the clinical information can be located.
Joint Commission does not approve auto authentication of entries in a health record.
The primary objection to this practice is that
it is too easy to delegate use of computer passwords.
electronic signatures are not acceptable in every state.
evidence cannot be provided that the physician actually reviewed and approved each
report.
tampering too often occurs with this method of authentication. - ANSWER evidence
cannot be provided that the physician actually reviewed and approved each report
Auto authentication is a policy adopted by some facilities that allow physicians to state
in advance that transcribed reports should automatically be considered approved and
signed (or authenticated) when the physician fails to make corrections within a
preestablished time frame (e.g., "Consider it signed if I do not make changes within 7
days."). Another version of this practice is when physicians authorize the HIM
department to send weekly lists of unsigned documents. The physician then signs the
list in lieu of signing each individual report. Neither practice ensures that the physician
has reviewed and approved each report individually.
One of the patients at your physician group practice has asked for an electronic copy of
her medical record. Your electronic computer system will not allow you to accommodate
this request. Chances are, you are NOT in compliance with
the HIPAA Privacy Rule.
Conditions of Coverage rules.
meaningful use requirements.
Joint Commission standards. - ANSWER meaningful use requirements
Certified EHRs must have the functionality to allow the creation of an electronic copy of
the patient's health record.
, In the past, Joint Commission standards have focused on promoting the use of a
facility-approved abbreviation list to be used by hospital care providers. With the advent
of the commission's national patient safety goals, the focus has shifted to the
use of prohibited or "dangerous" abbreviations.
prohibited use of any abbreviations.
use of abbreviations in the final diagnosis.
flagrant use of specialty-specific abbreviations. - ANSWER use of prohibited or
"dangerous" abbreviations.
As part of its National Patient Safety Goals initiative, the Joint Commission required
hospitals to prohibit abbreviations that have caused confusion or problems in their
handwritten form, such as "U" for unit, which can be mistaken for "O". Spelling out the
word "unit" is preferred.
One of the Joint Commission National Patient Safety Goals (NSPGs) requires that
health care organizations eliminate wrong-site, wrong-patient, and wrong-procedure
surgery. In order to accomplish this, which of the following would NOT be considered
part of a preoperative verification process?
Review the medical records and/or imaging studies.
Follow the daily surgical patient listing for the surgery suite if the patient has been
sedated.
Confirm the patient's true identity.
Mark the surgical site. - ANSWER Follow the daily surgical patient listing for the
surgery suite if the patient has been sedated
"Confirm the patient's true identity," "mark the surgical site," and "review the medical
records and/or imaging studies"—these are usually in the protocol to prevent wrong site,
wrong patient, or wrong surgery. The correct answer is following the daily surgical
patient listing—that choice would NOT be an appropriate step in making sure you have
the correct identity of the patient, the correct site, or the correct surgery.
A risk manager needs to locate a full report of a patient's fall from his bed, including
witness reports and probable reasons for the fall. She would most likely find this
information in the
nurses' notes.
integrated progress notes.
incident report.
doctors' progress notes. - ANSWER incident report.
Factual summaries investigating unexpected facility events should not be treated as
part of the patient's health information and therefore would not be recorded in the health
record.
ANSWERS(RATED A+)
For continuity of care, ambulatory care providers are more likely than providers of acute
care services to rely on the documentation found in the
interdisciplinary patient care plan.
discharge summary.
transfer record.For continuity of care, ambulatory care providers are more likely than
providers of acute care services to rely on the documentation found in the
interdisciplinary patient care plan.
problem list.
discharge summary.
transfer record. - ANSWER
Discharge summary documentation must include
correct codes for significant procedures.
a note from social services or discharge planning.
significant findings during hospitalization.
a detailed history of the patient. - ANSWER significant findings during hospitalization.
Some reference to the patient's history may be found in the discharge summary but not
a detailed history. The attending physician rather than a social worker records the
discharge summary. Procedure codes are usually recorded on a different form in the
record.
In preparation for an EHR, you are conducting a total facility inventory of all forms
currently used. You must name each form for bar coding and indexing into a document
management system. The unnamed document in front of you includes a microscopic
description of tissue excised during surgery. The document type you are most likely to
give to this form is
operative report.
discharge summary.
pathology report.
recovery room record. - ANSWER pathology report.
Although a gross description of tissue removed may be mentioned on the operative note
or discharge summary, only the pathology report will contain a microscopic description.
,You have been asked to identify every reportable case of cancer from the previous
year. A key resource will be the facility's
disease index.
physicians' index.
number control index.
patient index. - ANSWER disease index.
The major sources of case findings for cancer registry programs are the pathology
department, the disease index, and the logs of patients treated in radiology and other
outpatient departments. The number index identifies new health record numbers and
the patients to whom they were assigned. The physicians' index identifies all patients
treated by each doctor. The patient index links each patient treated in a facility with the
health number under which the clinical information can be located.
Joint Commission does not approve auto authentication of entries in a health record.
The primary objection to this practice is that
it is too easy to delegate use of computer passwords.
electronic signatures are not acceptable in every state.
evidence cannot be provided that the physician actually reviewed and approved each
report.
tampering too often occurs with this method of authentication. - ANSWER evidence
cannot be provided that the physician actually reviewed and approved each report
Auto authentication is a policy adopted by some facilities that allow physicians to state
in advance that transcribed reports should automatically be considered approved and
signed (or authenticated) when the physician fails to make corrections within a
preestablished time frame (e.g., "Consider it signed if I do not make changes within 7
days."). Another version of this practice is when physicians authorize the HIM
department to send weekly lists of unsigned documents. The physician then signs the
list in lieu of signing each individual report. Neither practice ensures that the physician
has reviewed and approved each report individually.
One of the patients at your physician group practice has asked for an electronic copy of
her medical record. Your electronic computer system will not allow you to accommodate
this request. Chances are, you are NOT in compliance with
the HIPAA Privacy Rule.
Conditions of Coverage rules.
meaningful use requirements.
Joint Commission standards. - ANSWER meaningful use requirements
Certified EHRs must have the functionality to allow the creation of an electronic copy of
the patient's health record.
, In the past, Joint Commission standards have focused on promoting the use of a
facility-approved abbreviation list to be used by hospital care providers. With the advent
of the commission's national patient safety goals, the focus has shifted to the
use of prohibited or "dangerous" abbreviations.
prohibited use of any abbreviations.
use of abbreviations in the final diagnosis.
flagrant use of specialty-specific abbreviations. - ANSWER use of prohibited or
"dangerous" abbreviations.
As part of its National Patient Safety Goals initiative, the Joint Commission required
hospitals to prohibit abbreviations that have caused confusion or problems in their
handwritten form, such as "U" for unit, which can be mistaken for "O". Spelling out the
word "unit" is preferred.
One of the Joint Commission National Patient Safety Goals (NSPGs) requires that
health care organizations eliminate wrong-site, wrong-patient, and wrong-procedure
surgery. In order to accomplish this, which of the following would NOT be considered
part of a preoperative verification process?
Review the medical records and/or imaging studies.
Follow the daily surgical patient listing for the surgery suite if the patient has been
sedated.
Confirm the patient's true identity.
Mark the surgical site. - ANSWER Follow the daily surgical patient listing for the
surgery suite if the patient has been sedated
"Confirm the patient's true identity," "mark the surgical site," and "review the medical
records and/or imaging studies"—these are usually in the protocol to prevent wrong site,
wrong patient, or wrong surgery. The correct answer is following the daily surgical
patient listing—that choice would NOT be an appropriate step in making sure you have
the correct identity of the patient, the correct site, or the correct surgery.
A risk manager needs to locate a full report of a patient's fall from his bed, including
witness reports and probable reasons for the fall. She would most likely find this
information in the
nurses' notes.
integrated progress notes.
incident report.
doctors' progress notes. - ANSWER incident report.
Factual summaries investigating unexpected facility events should not be treated as
part of the patient's health information and therefore would not be recorded in the health
record.
