AHIMA CCA Exam – Questions With Expert Solutions
In preparation for an EHR, you are 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.)Pathology b.) operative report c.)discharge summary d.) recovery room
record Accurate Answer:- Pathology report
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. cognitive patterns.
b. procedures and dates.
c. principal diagnosis.
d. personal identification. Accurate Answer:- cognitive patterns
.
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. flagrant use of specialty-specific abbreviations.
b. use of prohibited or "dangerous" abbreviations.
c. prohibited use of any abbreviations.
d. use of abbreviations in the final diagnosis. Accurate Answer:- Use of
prohibited of "dangerous"abbreviations
Engaging patients and their families in health care decisions is one of the core
objectives for
a. the Joint Commission's National Patient Safety goals.
b. HIPAA 5010 regulations.
,c. achieving meaningful use of EHRs.
d. establishing flexible clinical pathways. Accurate Answer:- Achieving
meaningful use of EHR's
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. integrated progress notes.
b. incident report.
c. doctors' progress notes.
d. nurses' notes. Accurate Answer:- incident report
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. discharge summary.
b. transfer record.
c. interdisciplinary patient care plan.
d. problem list. Accurate Answer:- problem list
Joint Commission does not approve of auto authentication of entries in a
health record. The primary objection to this practice is that
a. evidence cannot be provided that the physician actually reviewed and
approved each report.
b. electronic signatures are not acceptable in every state.
c. it is too easy to delegate use of computer passwords.
d. tampering too often occurs with this method of authentication.
Accurate Answer:- evidence cannot be provided that the physician actually
reviewed and approved each report
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. labor and delivery record.
b. postpartum record.
, c. prenatal record.
d. discharge summary. Accurate Answer:- prenatal record
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. that you apologize for not noticing the H&P she provided.
b. the H&P copy is acceptable as long as she documents any interval changes.
c. a new H&P is required for every inpatient admission.
d. Joint Commission standards do not allow copies of any kind in the original
record. Accurate Answer:- the h&p is acceptable as long as she doc any
interval change
You have been asked to identify every reportable case of cancer from the
previous year. A key resource will be the facility's
a. number control index.
b. physicians' index.
c. disease index.
d. patient index. Accurate Answer:- disease index
Joint Commission requires the attending physician to countersign health
record documentation that is entered by
a. business associates.
b. consulting physicians.
c. interns or medical students.
d. physician partners. Accurate Answer:- interns or medical student
The minimum length of time for retaining original medical records is
primarily governed by
a. medical staff.
b. state law.
c. Joint Commission.
d. readmission rates. Accurate Answer:- state law
In preparation for an EHR, you are 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.)Pathology b.) operative report c.)discharge summary d.) recovery room
record Accurate Answer:- Pathology report
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. cognitive patterns.
b. procedures and dates.
c. principal diagnosis.
d. personal identification. Accurate Answer:- cognitive patterns
.
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. flagrant use of specialty-specific abbreviations.
b. use of prohibited or "dangerous" abbreviations.
c. prohibited use of any abbreviations.
d. use of abbreviations in the final diagnosis. Accurate Answer:- Use of
prohibited of "dangerous"abbreviations
Engaging patients and their families in health care decisions is one of the core
objectives for
a. the Joint Commission's National Patient Safety goals.
b. HIPAA 5010 regulations.
,c. achieving meaningful use of EHRs.
d. establishing flexible clinical pathways. Accurate Answer:- Achieving
meaningful use of EHR's
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. integrated progress notes.
b. incident report.
c. doctors' progress notes.
d. nurses' notes. Accurate Answer:- incident report
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. discharge summary.
b. transfer record.
c. interdisciplinary patient care plan.
d. problem list. Accurate Answer:- problem list
Joint Commission does not approve of auto authentication of entries in a
health record. The primary objection to this practice is that
a. evidence cannot be provided that the physician actually reviewed and
approved each report.
b. electronic signatures are not acceptable in every state.
c. it is too easy to delegate use of computer passwords.
d. tampering too often occurs with this method of authentication.
Accurate Answer:- evidence cannot be provided that the physician actually
reviewed and approved each report
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. labor and delivery record.
b. postpartum record.
, c. prenatal record.
d. discharge summary. Accurate Answer:- prenatal record
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. that you apologize for not noticing the H&P she provided.
b. the H&P copy is acceptable as long as she documents any interval changes.
c. a new H&P is required for every inpatient admission.
d. Joint Commission standards do not allow copies of any kind in the original
record. Accurate Answer:- the h&p is acceptable as long as she doc any
interval change
You have been asked to identify every reportable case of cancer from the
previous year. A key resource will be the facility's
a. number control index.
b. physicians' index.
c. disease index.
d. patient index. Accurate Answer:- disease index
Joint Commission requires the attending physician to countersign health
record documentation that is entered by
a. business associates.
b. consulting physicians.
c. interns or medical students.
d. physician partners. Accurate Answer:- interns or medical student
The minimum length of time for retaining original medical records is
primarily governed by
a. medical staff.
b. state law.
c. Joint Commission.
d. readmission rates. Accurate Answer:- state law
