CCS EXAM PREP EXAM PRACTICE
VERIFIED QUESTIONS AND CORRECT
ANSWERS 2025/2026.
Impaired Glucose Tolerence - Correct Answer>>Dx given to
people who have blood sugar levels higher than normal but not
enough to be given the dx of diabetes
Brittle Diabetic - Correct Answer>>Blood sugars quickly swing
from high to low and from low to high (unstable) Extrinsic
Asthma - Correct Answer>>patients with this type of asthma
have a family hx of asthma
Review Of Systems - Correct Answer>>Physician asks patient a
series of questions about how they feel.
Usually organized by body system
The physician does not touch the patient during ROS
Impression - Correct Answer>>Physicians opinion on what is
wrong with the patient (admitting dx)
Timing of H&P - Correct Answer>>Must be documented within
24hrs of admission
Must be documented before surgery
Can be documented no more than 7 days prior to admission If
pt is readmitted within 30 days for the same condition the
physician may use an "interval note"
,Standing Orders - Correct Answer>>Orders established by a
physician that apply to a particular dx or condition
Verbal Orders - Correct Answer>>Usually by telephone
According to Medicare Conditions Of Participation state verbal
order should be authenticated within 48 hrs
Discharge Orders - Correct Answer>>Written at time physician
decides patient is ready to go home or be transferred to
another facility
Clinical Information - Correct Answer>>Medical Hx
Dx Theraputic Orders
Observations
Purpose of Uniform Healthcare Data Sets - Correct
Answer>>Ensure data collection for every patient is consistent
Enables comparison of health care data on a national level for
analysis
Interval Note - Correct Answer>>Info about pt current
complaint
Any relevant changes in condition
Physical Findings since last admission
Progress Note - Correct Answer>>Chronological record of the
clinical observations of the pt condition and response to
treatment during the hospital stay
Supports medical necessity
Written every 1 to 2 days
, The more often the notes are written the better Flow Charts -
Correct Answer>>Used to document pain assessments,
intake/output of fluid in the body in graphic form Graphic
Records - Correct Answer>>Used to document vital signs
Clinical Protocols - Correct Answer>>Describe a specific
procedure step-by-step
Kept as permanent part of the health record
Facility specific
Case Management - Correct Answer>>Ongoing review of
medical care to ensure the necessity and effectiveness of the
services being provided to the patient
Charting By Exception - Correct Answer>>Document only
abnormal/unusual findings, treatment rendered or patient
response
Clinical Practice Guidelines - Correct Answer>>Guidelines which
support and standardize clinical decision making for specific
medical conditions
Care Plan - Correct Answer>>A multidisciplinary tool for
organizing the diagnostic and therapeutic services to be
provided to a patient
Discharge Summary Timeliness - Correct Answer>>Completed
by attending physician within 30 days of discharge A
discharge note may be substituted for a discharge summary
when......... - Correct Answer>>hospitalization < 48hrs for an
uncomplicated stay
VERIFIED QUESTIONS AND CORRECT
ANSWERS 2025/2026.
Impaired Glucose Tolerence - Correct Answer>>Dx given to
people who have blood sugar levels higher than normal but not
enough to be given the dx of diabetes
Brittle Diabetic - Correct Answer>>Blood sugars quickly swing
from high to low and from low to high (unstable) Extrinsic
Asthma - Correct Answer>>patients with this type of asthma
have a family hx of asthma
Review Of Systems - Correct Answer>>Physician asks patient a
series of questions about how they feel.
Usually organized by body system
The physician does not touch the patient during ROS
Impression - Correct Answer>>Physicians opinion on what is
wrong with the patient (admitting dx)
Timing of H&P - Correct Answer>>Must be documented within
24hrs of admission
Must be documented before surgery
Can be documented no more than 7 days prior to admission If
pt is readmitted within 30 days for the same condition the
physician may use an "interval note"
,Standing Orders - Correct Answer>>Orders established by a
physician that apply to a particular dx or condition
Verbal Orders - Correct Answer>>Usually by telephone
According to Medicare Conditions Of Participation state verbal
order should be authenticated within 48 hrs
Discharge Orders - Correct Answer>>Written at time physician
decides patient is ready to go home or be transferred to
another facility
Clinical Information - Correct Answer>>Medical Hx
Dx Theraputic Orders
Observations
Purpose of Uniform Healthcare Data Sets - Correct
Answer>>Ensure data collection for every patient is consistent
Enables comparison of health care data on a national level for
analysis
Interval Note - Correct Answer>>Info about pt current
complaint
Any relevant changes in condition
Physical Findings since last admission
Progress Note - Correct Answer>>Chronological record of the
clinical observations of the pt condition and response to
treatment during the hospital stay
Supports medical necessity
Written every 1 to 2 days
, The more often the notes are written the better Flow Charts -
Correct Answer>>Used to document pain assessments,
intake/output of fluid in the body in graphic form Graphic
Records - Correct Answer>>Used to document vital signs
Clinical Protocols - Correct Answer>>Describe a specific
procedure step-by-step
Kept as permanent part of the health record
Facility specific
Case Management - Correct Answer>>Ongoing review of
medical care to ensure the necessity and effectiveness of the
services being provided to the patient
Charting By Exception - Correct Answer>>Document only
abnormal/unusual findings, treatment rendered or patient
response
Clinical Practice Guidelines - Correct Answer>>Guidelines which
support and standardize clinical decision making for specific
medical conditions
Care Plan - Correct Answer>>A multidisciplinary tool for
organizing the diagnostic and therapeutic services to be
provided to a patient
Discharge Summary Timeliness - Correct Answer>>Completed
by attending physician within 30 days of discharge A
discharge note may be substituted for a discharge summary
when......... - Correct Answer>>hospitalization < 48hrs for an
uncomplicated stay
