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CCA Exam Prep Domain 3 Health Records
and Data Content. Exam Questions and
Answers 100% Pass
Which of the following elements is -not- a component of most patient records? -
ANS Financial information
Identify where the following information would be found in the 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. - ANS 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, HCT 43.3, MCV 93. - ANS Medical laboratory 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." -
ANS Radiography report
The ______ provided the impetus for standardizing health care records with the minimum
standards early in the twentieth century: - ANS ACS
The following is documented in an acute-care record: "Microscopic: Sections are of squamous
mucosa with no atypia." What would this documentation be found? - ANS Pathology report
, ©THESTAR 2025 ALL RIGHTS RESERVED
The following is documented in an acute-care record: "Admit to 3C. Diet: NPO. Meds:
Compazine 10 mg IV Q 6 PRN." Where would this documentation be found? - ANS Admission
order
The following is documented in an acute-care record: "38 weeks gestation, Apgars 8/9, 6# 9.8
oz, good cry." Where would this documentation be found? - ANS Newborn record
The following is documented in an acute-care record: "Atrial fibrillation with rapid ventricular
response, left axis deviation, left bundle branch block." Where would this documentation be
found? - ANS ECG report
The regulations for health care record content and documentation, guidelines and regulations
for which facilities are allowed to take part in or join the Medicare and Medicaid programs is: -
ANS Conditions of Participation
The following is documented in an acute-care record: "Spoke to the attending re: my
assessment. Provided adoption and counseling information. Spoke to CPS re: referral. Case
manager to meet with patient and family." Where would this documentation be found? -
ANS 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 ______. - ANS UHDDS
Even though state laws may be more stringent, CMS requires acute healthcare records to be
maintained by the acute health care organization for: - ANS At least 5 years
A notation for diabetic patient in a physician note reads: "Occasionally gets hungry. No insulin
reactions. Says she is following her diabetic diet." Which part of a POMR progress note would
this notation be written? - ANS Subjective
CCA Exam Prep Domain 3 Health Records
and Data Content. Exam Questions and
Answers 100% Pass
Which of the following elements is -not- a component of most patient records? -
ANS Financial information
Identify where the following information would be found in the 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. - ANS 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, HCT 43.3, MCV 93. - ANS Medical laboratory 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." -
ANS Radiography report
The ______ provided the impetus for standardizing health care records with the minimum
standards early in the twentieth century: - ANS ACS
The following is documented in an acute-care record: "Microscopic: Sections are of squamous
mucosa with no atypia." What would this documentation be found? - ANS Pathology report
, ©THESTAR 2025 ALL RIGHTS RESERVED
The following is documented in an acute-care record: "Admit to 3C. Diet: NPO. Meds:
Compazine 10 mg IV Q 6 PRN." Where would this documentation be found? - ANS Admission
order
The following is documented in an acute-care record: "38 weeks gestation, Apgars 8/9, 6# 9.8
oz, good cry." Where would this documentation be found? - ANS Newborn record
The following is documented in an acute-care record: "Atrial fibrillation with rapid ventricular
response, left axis deviation, left bundle branch block." Where would this documentation be
found? - ANS ECG report
The regulations for health care record content and documentation, guidelines and regulations
for which facilities are allowed to take part in or join the Medicare and Medicaid programs is: -
ANS Conditions of Participation
The following is documented in an acute-care record: "Spoke to the attending re: my
assessment. Provided adoption and counseling information. Spoke to CPS re: referral. Case
manager to meet with patient and family." Where would this documentation be found? -
ANS 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 ______. - ANS UHDDS
Even though state laws may be more stringent, CMS requires acute healthcare records to be
maintained by the acute health care organization for: - ANS At least 5 years
A notation for diabetic patient in a physician note reads: "Occasionally gets hungry. No insulin
reactions. Says she is following her diabetic diet." Which part of a POMR progress note would
this notation be written? - ANS Subjective
