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CCA Exam Prep - Health Records and Data
Content. Exam Questions and Answers 100%
Pass
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) - ANS a. United Network of Organ Sharing (UNOS)
A notation for a hypertensive patient in a physician ambulatory care progress note reads:
"Continue with Diuril, 500 mgs once daily. Return visit in 2 weeks." Which part of a POMR
progress note would this notation be written?
a. Subjective
b. Objective
c. Assessment
d. Plan - ANS d. Plan
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
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b. Behavioral health
c. End-stage renal disease
d. Rehabilitative care - ANS a. Home health
Who is responsible for writing and signing discharge summaries and discharge instructions?
a. Attending physician
b. Head nurse
c. Primary physician
d. Admitting nurse - ANS a. Attending physician
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 - ANS c. Patient's complete
medical history
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
c. Secondary
d. Financial - ANS a. clinical
Which of the following elements is not a component of most patient records?
a. Patient identification
b. Clinical history
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c. Financial information
d. Test results - ANS c. financial information
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 - ANS b. vital signs
Identify where the following information would be found in the acute-care record: "PA and
Lateral Chest: The lungs are clear. The heart and mediastinum are normal in size and
configuration. There are minor degenerative changes of the lower thoracic spine."
a. Medical laboratory report
b. Physical examination
c. Physician progress note
d. Radiography report - ANS d. Radiography report
Which of the following represents documentation of the patient's current and past health
status?
a. Physical examination
b. Medical history
c. Physician orders
d. Patient consent - ANS b. Medical history
What is the function of physician's orders?
a. Provide a chronological summary of the patient's illness and treatment
b. Document the patient's current and past health status
CCA Exam Prep - Health Records and Data
Content. Exam Questions and Answers 100%
Pass
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) - ANS a. United Network of Organ Sharing (UNOS)
A notation for a hypertensive patient in a physician ambulatory care progress note reads:
"Continue with Diuril, 500 mgs once daily. Return visit in 2 weeks." Which part of a POMR
progress note would this notation be written?
a. Subjective
b. Objective
c. Assessment
d. Plan - ANS d. Plan
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
, ©THESTAR 2025 ALL RIGHTS RESERVED
b. Behavioral health
c. End-stage renal disease
d. Rehabilitative care - ANS a. Home health
Who is responsible for writing and signing discharge summaries and discharge instructions?
a. Attending physician
b. Head nurse
c. Primary physician
d. Admitting nurse - ANS a. Attending physician
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 - ANS c. Patient's complete
medical history
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
c. Secondary
d. Financial - ANS a. clinical
Which of the following elements is not a component of most patient records?
a. Patient identification
b. Clinical history
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c. Financial information
d. Test results - ANS c. financial information
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 - ANS b. vital signs
Identify where the following information would be found in the acute-care record: "PA and
Lateral Chest: The lungs are clear. The heart and mediastinum are normal in size and
configuration. There are minor degenerative changes of the lower thoracic spine."
a. Medical laboratory report
b. Physical examination
c. Physician progress note
d. Radiography report - ANS d. Radiography report
Which of the following represents documentation of the patient's current and past health
status?
a. Physical examination
b. Medical history
c. Physician orders
d. Patient consent - ANS b. Medical history
What is the function of physician's orders?
a. Provide a chronological summary of the patient's illness and treatment
b. Document the patient's current and past health status
