CCS EXAM PREP QUESTIONS AND
VERIFIED OPTIONS
Impaired Glucose Tolerance ✅✅ANSW-Dx given to people who have blood sugar levels higher
than normal but not enough to be given the dx of diabetes
Brittle Diabetic ✅✅ANSW-Blood sugars quickly swing from high to low and from low to high
(unstable)
Extrinsic Asthma ✅✅ANSW-patients with this type of asthma have a family hx of asthma
Review Of Systems ✅✅ANSW-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 ✅✅ANSW-Physicians opinion on what is wrong with the patient (admitting dx)
Timing of H&P ✅✅ANSW-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 ✅✅ANSW-Orders established by a physician that apply to a particular dx or
condition
Verbal Orders ✅✅ANSW-Usually by telephone
According to Medicare Conditions Of Participation state verbal order should be authenticated within
48 hrs
Discharge Orders ✅✅ANSW-Written at time physician decides patient is ready to go home or be
transferred to another facility
, Clinical Information ✅✅ANSW-Medical Hx
Dx Theraputic Orders
Observations
Purpose of Uniform Healthcare Data Sets ✅✅ANSW-Ensure data collection for every patient is
consistent
Enables comparison of health care data on a national level for analysis
Interval Note ✅✅ANSW-Info about pt current complaint
Any relevant changes in condition
Physical Findings since last admission
Progress Note ✅✅ANSW-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 ✅✅ANSW-Used to document pain assessments, intake/output of fluid in the body in
graphic form
Graphic Records ✅✅ANSW-Used to document vital signs
Clinical Protocols ✅✅ANSW-Describe a specific procedure step-by-step
Kept as permanent part of the health record
Facility specific
Case Management ✅✅ANSW-Ongoing review of medical care to ensure the necessity and
effectiveness of the services being provided to the patient
VERIFIED OPTIONS
Impaired Glucose Tolerance ✅✅ANSW-Dx given to people who have blood sugar levels higher
than normal but not enough to be given the dx of diabetes
Brittle Diabetic ✅✅ANSW-Blood sugars quickly swing from high to low and from low to high
(unstable)
Extrinsic Asthma ✅✅ANSW-patients with this type of asthma have a family hx of asthma
Review Of Systems ✅✅ANSW-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 ✅✅ANSW-Physicians opinion on what is wrong with the patient (admitting dx)
Timing of H&P ✅✅ANSW-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 ✅✅ANSW-Orders established by a physician that apply to a particular dx or
condition
Verbal Orders ✅✅ANSW-Usually by telephone
According to Medicare Conditions Of Participation state verbal order should be authenticated within
48 hrs
Discharge Orders ✅✅ANSW-Written at time physician decides patient is ready to go home or be
transferred to another facility
, Clinical Information ✅✅ANSW-Medical Hx
Dx Theraputic Orders
Observations
Purpose of Uniform Healthcare Data Sets ✅✅ANSW-Ensure data collection for every patient is
consistent
Enables comparison of health care data on a national level for analysis
Interval Note ✅✅ANSW-Info about pt current complaint
Any relevant changes in condition
Physical Findings since last admission
Progress Note ✅✅ANSW-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 ✅✅ANSW-Used to document pain assessments, intake/output of fluid in the body in
graphic form
Graphic Records ✅✅ANSW-Used to document vital signs
Clinical Protocols ✅✅ANSW-Describe a specific procedure step-by-step
Kept as permanent part of the health record
Facility specific
Case Management ✅✅ANSW-Ongoing review of medical care to ensure the necessity and
effectiveness of the services being provided to the patient
