CCS Exam Prep Health Data Content and
Standards fully solved A+ graded
B - correct answer ✔✔1. In preparation for an EHR, you are working with a team conducting a
total facility inventory of all forms currently used. You must name each form for bar coding and
indexing into a document management system. The unnamed document in front of you
includes a microscopic description of tissue excised during surgery. The document type you are
most likely to give to this form is
A. recovery room record. C. operative report. B. pathology report. D. discharge summary.
B - correct answer ✔✔2. 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. personal identification. C. procedures and dates. B. cognitive patterns. D. principal diagnosis.
C - correct answer ✔✔3. 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. prohibited use of any abbreviations. B. flagrant use of specialty-specific abbreviations. C. use
of prohibited or "dangerous" abbreviations. D. use of abbreviations used in the final diagnosis.
C - correct answer ✔✔4. 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.
doctors' progress notes. C. incident report. B. integrated progress notes. D. nurses' notes.
D - correct answer ✔✔5. 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. interdisciplinary patient care plan. B.
discharge summary. C. transfer record. D. problem list.
B - correct answer ✔✔6. Joint Commission does not approve of auto authentication of entries
in a health record. The
primary objection to this practice is that A. it is too easy to delegate use of computer passwords.
B. evidence cannot be provided that the physician actually reviewed and approved each report.
C. electronic signatures are not acceptable in every state. D. tampering too often occurs with
this method of authentication.
A - correct answer ✔✔7. 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. prenatal record. C. postpartum record. B. labor and delivery
record. D. discharge summary.
C - correct answer ✔✔8. 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. a new H&P is required for every inpatient
admission. B. that you apologize for not noticing the H&P she provided. C. the H&P copy is
acceptable as long as she documents any interval changes. D. Joint Commission standards do
not allow copies of any kind in the original record.
A - correct answer ✔✔9. You have been asked to identify every reportable case of cancer from
the previous year. A key
resource will be the facility's A. disease index. C. physicians' index. B. number control index. D.
patient index.
C - correct answer ✔✔10. Discharge summary documentation must include
A. a detailed history of the patient. B. a note from social services or discharge planning. C.
significant findings during hospitalization. D. correct codes for significant procedures.
Standards fully solved A+ graded
B - correct answer ✔✔1. In preparation for an EHR, you are working with a team conducting a
total facility inventory of all forms currently used. You must name each form for bar coding and
indexing into a document management system. The unnamed document in front of you
includes a microscopic description of tissue excised during surgery. The document type you are
most likely to give to this form is
A. recovery room record. C. operative report. B. pathology report. D. discharge summary.
B - correct answer ✔✔2. 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. personal identification. C. procedures and dates. B. cognitive patterns. D. principal diagnosis.
C - correct answer ✔✔3. 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. prohibited use of any abbreviations. B. flagrant use of specialty-specific abbreviations. C. use
of prohibited or "dangerous" abbreviations. D. use of abbreviations used in the final diagnosis.
C - correct answer ✔✔4. 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.
doctors' progress notes. C. incident report. B. integrated progress notes. D. nurses' notes.
D - correct answer ✔✔5. 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. interdisciplinary patient care plan. B.
discharge summary. C. transfer record. D. problem list.
B - correct answer ✔✔6. Joint Commission does not approve of auto authentication of entries
in a health record. The
primary objection to this practice is that A. it is too easy to delegate use of computer passwords.
B. evidence cannot be provided that the physician actually reviewed and approved each report.
C. electronic signatures are not acceptable in every state. D. tampering too often occurs with
this method of authentication.
A - correct answer ✔✔7. 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. prenatal record. C. postpartum record. B. labor and delivery
record. D. discharge summary.
C - correct answer ✔✔8. 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. a new H&P is required for every inpatient
admission. B. that you apologize for not noticing the H&P she provided. C. the H&P copy is
acceptable as long as she documents any interval changes. D. Joint Commission standards do
not allow copies of any kind in the original record.
A - correct answer ✔✔9. You have been asked to identify every reportable case of cancer from
the previous year. A key
resource will be the facility's A. disease index. C. physicians' index. B. number control index. D.
patient index.
C - correct answer ✔✔10. Discharge summary documentation must include
A. a detailed history of the patient. B. a note from social services or discharge planning. C.
significant findings during hospitalization. D. correct codes for significant procedures.
