CCA Exam Prep - Health Records and Data Content.pdf file:///C:/Users/HP/Desktop/New%20folder%20(2)/CCA%20Exam%
CCA Exam Prep - Health Records and Data
Content Questions & Answers
1. The Joint Commission and CMS require hospitals to inform families of the
opportunity to donate organs, tissue, or eyes. The name of the criteria that
potential donors must meet is .
a. United Network of Organ Sharing (UNOS)
b. Conditions of Participation
c. Personal Health Record (PHR)
d. Do Not Resuscitate (DNR)
Answer a. United Network of Organ Sharing (UNOS)
2. A notation for a hypertensive patient in a physician ambulatory care
progress note reads "Continue with Diuril, 500 mgs once daily. Return visit in2
weeks."Which part of a POMR progress note would this notation be written?
a. Subjective
b. Objective
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,CCA Exam Prep - Health Records and Data Content.pdf file:///C:/Users/HP/Desktop/New%20folder%20(2)/CCA%20Exam%
c. Assessment
d. Plan
Answer d. Plan
3. Documentation of aides who assist a patient with activities of daily living,
bathing, laundry, and cleaning would be found in which type of specialty
record?
a. Home health
b. Behavioral health
c. End-stage renal disease
d. Rehabilitative care
Answer a. Home health
4. Who is responsible for writing and signing discharge summaries and dis-
charge instructions?
a. Attending physician
b. Head nurse
c. Primary physician
d. Admitting nurse
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,CCA Exam Prep - Health Records and Data Content.pdf file:///C:/Users/HP/Desktop/New%20folder%20(2)/CCA%20Exam%
Answer a. Attending physician
5. Which of the following materials is not documented in an emergency care
record?
a. Patient's instructions at discharge
b. Time and means of the patient's arrival
c. Patient's complete medical history
d. Emergency care administered before arrival at the facility
Answer c. Patient's com-plete medical history
6. All documentation entered in the medical record relating to the patient's
diagnosis and treatment is considered as this type of data
a. Clinical
b. Identification
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,CCA Exam Prep - Health Records and Data Content.pdf file:///C:/Users/HP/Desktop/New%20folder%20(2)/CCA%20Exam%
c. Secondary
d. Financial
Answer a. clinical
7. Which of the following elements is not a component of most patient
records?
a. Patient identification
b. Clinical history
c. Financial information
d. Test results
Answer c. financial information
8. Which of the following would not be found in a medical history?
a. Chief complaint
b. Vital signs
c. Present illness
d. Review of systems
Answer b. vital signs
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CCA Exam Prep - Health Records and Data
Content Questions & Answers
1. The Joint Commission and CMS require hospitals to inform families of the
opportunity to donate organs, tissue, or eyes. The name of the criteria that
potential donors must meet is .
a. United Network of Organ Sharing (UNOS)
b. Conditions of Participation
c. Personal Health Record (PHR)
d. Do Not Resuscitate (DNR)
Answer a. United Network of Organ Sharing (UNOS)
2. A notation for a hypertensive patient in a physician ambulatory care
progress note reads "Continue with Diuril, 500 mgs once daily. Return visit in2
weeks."Which part of a POMR progress note would this notation be written?
a. Subjective
b. Objective
1 of 36 12/10/2024, 11:31
,CCA Exam Prep - Health Records and Data Content.pdf file:///C:/Users/HP/Desktop/New%20folder%20(2)/CCA%20Exam%
c. Assessment
d. Plan
Answer d. Plan
3. Documentation of aides who assist a patient with activities of daily living,
bathing, laundry, and cleaning would be found in which type of specialty
record?
a. Home health
b. Behavioral health
c. End-stage renal disease
d. Rehabilitative care
Answer a. Home health
4. Who is responsible for writing and signing discharge summaries and dis-
charge instructions?
a. Attending physician
b. Head nurse
c. Primary physician
d. Admitting nurse
2 of 36 12/10/2024, 11:31
,CCA Exam Prep - Health Records and Data Content.pdf file:///C:/Users/HP/Desktop/New%20folder%20(2)/CCA%20Exam%
Answer a. Attending physician
5. Which of the following materials is not documented in an emergency care
record?
a. Patient's instructions at discharge
b. Time and means of the patient's arrival
c. Patient's complete medical history
d. Emergency care administered before arrival at the facility
Answer c. Patient's com-plete medical history
6. All documentation entered in the medical record relating to the patient's
diagnosis and treatment is considered as this type of data
a. Clinical
b. Identification
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,CCA Exam Prep - Health Records and Data Content.pdf file:///C:/Users/HP/Desktop/New%20folder%20(2)/CCA%20Exam%
c. Secondary
d. Financial
Answer a. clinical
7. Which of the following elements is not a component of most patient
records?
a. Patient identification
b. Clinical history
c. Financial information
d. Test results
Answer c. financial information
8. Which of the following would not be found in a medical history?
a. Chief complaint
b. Vital signs
c. Present illness
d. Review of systems
Answer b. vital signs
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