AHIMA CCA ACTUAL TEST QUESTIONS
WITH COMPLETE ANSWER KEY
●● Patient data collection requirements vary according to health care
setting. A data element you would expect to be collected in the MDS, but
NOT in the UHDDS would be
a. cognitive patterns.
b. procedures and dates.
c. principal diagnosis.
d. personal identification.
Answer: cognitive patterns
●● .
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
a. flagrant use of specialty-specific abbreviations.
,b. use of prohibited or "dangerous" abbreviations.
c. prohibited use of any abbreviations.
d. use of abbreviations in the final diagnosis.
Answer: Use of prohibited of "dangerous"abbreviations
●● Engaging patients and their families in health care decisions is one of
the core objectives for
a. the Joint Commission's National Patient Safety goals.
b. HIPAA 5010 regulations.
c. achieving meaningful use of EHRs.
d. establishing flexible clinical pathways.
Answer: Achieving meaningful use of EHR's
●● 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
a. integrated progress notes.
b. incident report.
c. doctors' progress notes.
d. nurses' notes.
Answer: incident report
,●● For continuity of care, ambulatory care providers are more likely
than providers of acute care services to rely on the documentation found
in the
a. discharge summary.
b. transfer record.
c. interdisciplinary patient care plan.
d. problem list.
Answer: problem list
●● Joint Commission does not approve of auto authentication of entries
in a health record. The primary objection to this practice is that
a. evidence cannot be provided that the physician actually reviewed and
approved each report.
b. electronic signatures are not acceptable in every state.
c. it is too easy to delegate use of computer passwords.
d. tampering too often occurs with this method of authentication.
Answer: evidence cannot be provided that the physician actually
reviewed and approved each report
●● As part of a quality improvement study, you have been asked to
provide information on the menstrual history, number of pregnancies,
, and number of living children on each OB patient from a stack of old
obstetrical records. The best place in the record to locate this information
is the
a. labor and delivery record.
b. postpartum record.
c. prenatal record.
d. discharge summary.
Answer: prenatal record
●● As a concurrent record reviewer for an acute care facility, you have
asked Dr. Crossman to provide an updated history and physical for one
of her recent admissions. Dr. Crossman pages through the medical
record to a copy of an H&P performed in her office a week before
admission. You tell Dr. Crossman
a. that you apologize for not noticing the H&P she provided.
b. the H&P copy is acceptable as long as she documents any interval
changes.
c. a new H&P is required for every inpatient admission.
d. Joint Commission standards do not allow copies of any kind in the
original record.
Answer: the h&p is acceptable as long as she doc any interval change
WITH COMPLETE ANSWER KEY
●● Patient data collection requirements vary according to health care
setting. A data element you would expect to be collected in the MDS, but
NOT in the UHDDS would be
a. cognitive patterns.
b. procedures and dates.
c. principal diagnosis.
d. personal identification.
Answer: cognitive patterns
●● .
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
a. flagrant use of specialty-specific abbreviations.
,b. use of prohibited or "dangerous" abbreviations.
c. prohibited use of any abbreviations.
d. use of abbreviations in the final diagnosis.
Answer: Use of prohibited of "dangerous"abbreviations
●● Engaging patients and their families in health care decisions is one of
the core objectives for
a. the Joint Commission's National Patient Safety goals.
b. HIPAA 5010 regulations.
c. achieving meaningful use of EHRs.
d. establishing flexible clinical pathways.
Answer: Achieving meaningful use of EHR's
●● 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
a. integrated progress notes.
b. incident report.
c. doctors' progress notes.
d. nurses' notes.
Answer: incident report
,●● For continuity of care, ambulatory care providers are more likely
than providers of acute care services to rely on the documentation found
in the
a. discharge summary.
b. transfer record.
c. interdisciplinary patient care plan.
d. problem list.
Answer: problem list
●● Joint Commission does not approve of auto authentication of entries
in a health record. The primary objection to this practice is that
a. evidence cannot be provided that the physician actually reviewed and
approved each report.
b. electronic signatures are not acceptable in every state.
c. it is too easy to delegate use of computer passwords.
d. tampering too often occurs with this method of authentication.
Answer: evidence cannot be provided that the physician actually
reviewed and approved each report
●● As part of a quality improvement study, you have been asked to
provide information on the menstrual history, number of pregnancies,
, and number of living children on each OB patient from a stack of old
obstetrical records. The best place in the record to locate this information
is the
a. labor and delivery record.
b. postpartum record.
c. prenatal record.
d. discharge summary.
Answer: prenatal record
●● As a concurrent record reviewer for an acute care facility, you have
asked Dr. Crossman to provide an updated history and physical for one
of her recent admissions. Dr. Crossman pages through the medical
record to a copy of an H&P performed in her office a week before
admission. You tell Dr. Crossman
a. that you apologize for not noticing the H&P she provided.
b. the H&P copy is acceptable as long as she documents any interval
changes.
c. a new H&P is required for every inpatient admission.
d. Joint Commission standards do not allow copies of any kind in the
original record.
Answer: the h&p is acceptable as long as she doc any interval change
