CCS Exam Prep: Master Key Concepts &
Practice Questions
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
Currency
...
Data Accessibility
data is available to those authorized to use it
Relevancy
...
Consistency
...
Benchmarking
Process of comparing an organization to a standard, a peer group, or other organization.
Ex. A hospital may want to compare its ALOS (average length of stay) with the ALOS for all hospitals
nationwide.
Continuum Of Care
Various types of healthcare services provided in diverse settings from basic primary care to complex
tertiary settings.
Primary Care
Practice Questions
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
Currency
...
Data Accessibility
data is available to those authorized to use it
Relevancy
...
Consistency
...
Benchmarking
Process of comparing an organization to a standard, a peer group, or other organization.
Ex. A hospital may want to compare its ALOS (average length of stay) with the ALOS for all hospitals
nationwide.
Continuum Of Care
Various types of healthcare services provided in diverse settings from basic primary care to complex
tertiary settings.
Primary Care
