CCS Exam Prep Questions & Answers | 127 Questions with 100% Correct Answers | Verified | Updated 2024

CCS Exam Prep Questions & Answers | 127 Questions with 100% Correct Answers | Verified | Updated 2024 Primary Data Source Patient specific/identifiable data Related to a specific individual ex. The Health Record Secondary Data Source Information on groups of people or patients without identifying any particular patient individually. Also called "Aggregate Data" Compiled from multiple health records Ex. Data taken from the health record and entered into registries and databases are considered secondary data. Confidentiality ... Security ... Privacy ... Quantitative Analysis Checking for the presence or absence of necessary reports or signatures. Ex. progress notes, orders Completeness and Accuracy Making sure a document is there and authenticated Focuses on physician documentation Qualitative Analysis Ex. Checking documentation consistency, such as contraindications in entries,progress note dated prior to admission etc Quality of records Does documentation reflect the quality of patient care provided Incident Report Written accounts of unusual events that have an adverse effect on a patient, employee, or facility visitor. Never filed in patient health record. Used by risk management and or attorney to investigate incidents that have the potential to become claims against the organization or individual provider. Incident An event considered to be inconsistent with accepted standards of care. Ex. res ipsa loquitor "the thing speaks for itself" The injury would not ordinarily occur without someones negligence Ex. Surgical instrument left in patient after surgery