CCA Exam Prep - Health Records and Data
Content CORRECT 100%
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) - ANSWER 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 - ANSWER 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
b. Behavioral health
c. End-stage renal disease
d. Rehabilitative care - ANSWER 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 - ANSWER 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 - ANSWER c. Patient's complete medical
history
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 - ANSWER 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
c. Document the physician's instructions to other parties involved in providing care to a patient
d. Document the provider's follow-up care instructions given to the patient or patient's caregiver -
ANSWER c. Document the physician's instructions to other parties involved in providing care to a patient
Even though state laws may be more stringent, CMS requires acute healthcare records to be maintained
by the acute health care organization for:
a. Ten years
b. At least 5 years
c. Minimum of 25 years
d. Permanent access - ANSWER b. At least 5 years
, The following is documented in an acute-care record: "Atrial fibrillation with rapid ventricular response,
left axis deviation, left bundle branch block." Where would this documentation be found?
a. Admission order
b. Clinical laboratory report
c. ECG report
d. Radiology report - ANSWER c. ECG report
A patient with known COPD and hypertension under treatment was admitted to the hospital with
symptoms of a lower abdominal pain. He undergoes a laparoscopic appendectomy and develops a fever.
The patient was subsequently discharged from the hospital with a principal diagnosis of acute
appendicitis and secondary diagnoses of postoperative infection, COPD, and hypertension. Which of the
following diagnoses should not be tagged as POA?
a. Postoperative infection
b. Appendicitis
c. COPD
d. Hypertension - ANSWER a. Postoperative infection
The ________ may contain information about diseases among relatives in which heredity may play a
role.
a. Physical examination
b. History
c. Laboratory report
d. Administrative data - ANSWER b. history
Which of the following provides macroscopic and microscopic information about tissue removed during
an operative procedure?
a. Anesthesia report
b. Laboratory report
c. Operative report
d. Pathology report - ANSWER d. Pathology report
All documentation entered in the medical record relating to the patient's diagnosis and treatment is
considered as this type of data:
Content CORRECT 100%
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) - ANSWER 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 - ANSWER 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
b. Behavioral health
c. End-stage renal disease
d. Rehabilitative care - ANSWER 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 - ANSWER 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 - ANSWER c. Patient's complete medical
history
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 - ANSWER 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
c. Document the physician's instructions to other parties involved in providing care to a patient
d. Document the provider's follow-up care instructions given to the patient or patient's caregiver -
ANSWER c. Document the physician's instructions to other parties involved in providing care to a patient
Even though state laws may be more stringent, CMS requires acute healthcare records to be maintained
by the acute health care organization for:
a. Ten years
b. At least 5 years
c. Minimum of 25 years
d. Permanent access - ANSWER b. At least 5 years
, The following is documented in an acute-care record: "Atrial fibrillation with rapid ventricular response,
left axis deviation, left bundle branch block." Where would this documentation be found?
a. Admission order
b. Clinical laboratory report
c. ECG report
d. Radiology report - ANSWER c. ECG report
A patient with known COPD and hypertension under treatment was admitted to the hospital with
symptoms of a lower abdominal pain. He undergoes a laparoscopic appendectomy and develops a fever.
The patient was subsequently discharged from the hospital with a principal diagnosis of acute
appendicitis and secondary diagnoses of postoperative infection, COPD, and hypertension. Which of the
following diagnoses should not be tagged as POA?
a. Postoperative infection
b. Appendicitis
c. COPD
d. Hypertension - ANSWER a. Postoperative infection
The ________ may contain information about diseases among relatives in which heredity may play a
role.
a. Physical examination
b. History
c. Laboratory report
d. Administrative data - ANSWER b. history
Which of the following provides macroscopic and microscopic information about tissue removed during
an operative procedure?
a. Anesthesia report
b. Laboratory report
c. Operative report
d. Pathology report - ANSWER d. Pathology report
All documentation entered in the medical record relating to the patient's diagnosis and treatment is
considered as this type of data:
