CCS EXAM PREP HEALTH DATA
CONTENT AND STANDARDS
QUESTIONS AND ANSWERS
B - Correct Answers -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 Answers -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 Answers -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 Answers -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 Answers -71. The Utilization Review Coordinator reviews inpatient records
at regular intervals to justify necessity and appropriateness of care to warrant further
hospitalization. Which of the following utilization review activities is being performed?
A. admission review C. retrospective review B. preadmission D. continued stay review
D - Correct Answers -72. Which feature is a trademark of an effective PI program?
, A. a one-time cure—all for a facility's problems B. an unmanageable project that is too
expensive C. a cost-containment effort D. a continuous cycle of improvement projects
over time
A - Correct Answers -73. Patient mortality, infection, and complication rates, adherence
to living will requirements, adequate pain control, and other documentation that describe
end results of care or a measurable change in the patient's health are examples of
A. outcome measures. C. sentinel events. B. threshold level. D. incident reports.
D - Correct Answers -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 Answers -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 Answers -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 Answers -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 Answers -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 Answers -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.
CONTENT AND STANDARDS
QUESTIONS AND ANSWERS
B - Correct Answers -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 Answers -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 Answers -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 Answers -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 Answers -71. The Utilization Review Coordinator reviews inpatient records
at regular intervals to justify necessity and appropriateness of care to warrant further
hospitalization. Which of the following utilization review activities is being performed?
A. admission review C. retrospective review B. preadmission D. continued stay review
D - Correct Answers -72. Which feature is a trademark of an effective PI program?
, A. a one-time cure—all for a facility's problems B. an unmanageable project that is too
expensive C. a cost-containment effort D. a continuous cycle of improvement projects
over time
A - Correct Answers -73. Patient mortality, infection, and complication rates, adherence
to living will requirements, adequate pain control, and other documentation that describe
end results of care or a measurable change in the patient's health are examples of
A. outcome measures. C. sentinel events. B. threshold level. D. incident reports.
D - Correct Answers -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 Answers -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 Answers -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 Answers -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 Answers -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 Answers -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.
