CCS EXAM PREP HEALTH DATA
CONTENT AND STANDARDS EXAM
QUESTIONS WITH ANSWERS 2026
B - ANSWERS1. 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 - ANSWERS2. 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 - ANSWERS3. 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 - ANSWERS4. 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 - ANSWERS5. 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 - ANSWERS6. 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 - ANSWERS7. 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 - ANSWERS8. 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 - ANSWERS9. 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 - ANSWERS10. 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.
D - ANSWERS11. The performance of qualitative analysis is an important tool in
ensuring data quality. These reviews evaluate
A. quality of care through the use of preestablished criteria. B. adverse effects and
contraindications of drugs utilized during hospitalization. C. potentially compensable
events. D. the overall quality of documentation.
B - ANSWERS12. Ultimate responsibility for the quality and completion of entries in
patient health records belongs
to the A. chief of staff. C. HIM director. B. attending physician. D. risk manager.
C - ANSWERS13. The foundation for communicating all patient care goals in long-term
care settings is the
A. legal assessment. C. interdisciplinary plan of care. B. medical history. D. Uniform
Hospital Discharge Data Set.
C - ANSWERS14. As part of Joint Commission's National Patient Safety Goal initiative,
acute care hospitals are now required to use a preoperative verification process to
confirm the patient's true identity and to confirm that necessary documents such as X-
rays or medical records are available. They must also develop and use a process for A.
CONTENT AND STANDARDS EXAM
QUESTIONS WITH ANSWERS 2026
B - ANSWERS1. 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 - ANSWERS2. 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 - ANSWERS3. 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 - ANSWERS4. 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 - ANSWERS5. 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 - ANSWERS6. 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 - ANSWERS7. 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 - ANSWERS8. 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 - ANSWERS9. 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 - ANSWERS10. 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.
D - ANSWERS11. The performance of qualitative analysis is an important tool in
ensuring data quality. These reviews evaluate
A. quality of care through the use of preestablished criteria. B. adverse effects and
contraindications of drugs utilized during hospitalization. C. potentially compensable
events. D. the overall quality of documentation.
B - ANSWERS12. Ultimate responsibility for the quality and completion of entries in
patient health records belongs
to the A. chief of staff. C. HIM director. B. attending physician. D. risk manager.
C - ANSWERS13. The foundation for communicating all patient care goals in long-term
care settings is the
A. legal assessment. C. interdisciplinary plan of care. B. medical history. D. Uniform
Hospital Discharge Data Set.
C - ANSWERS14. As part of Joint Commission's National Patient Safety Goal initiative,
acute care hospitals are now required to use a preoperative verification process to
confirm the patient's true identity and to confirm that necessary documents such as X-
rays or medical records are available. They must also develop and use a process for A.
