CCS Exam Prep Study Guide with Questions
and Correct Answers
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.
and Correct Answers
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.
