CCA Exam Prep Domain 3 Health Records
and Data Content CORRECT 100%
Which of the following elements is -not- a component of most patient records? - ANSWER Financial
information
Identify where the following information would be found in the acute-care record: Following induction of
an adequate general anesthesia, and with the patient supine on the padded table, the left upper
extremity was prepped and draped in the standard fashion. - ANSWER Operative Report
Identify where the following information would be found in the acute-care record: "CBC: WBC 12.0, RBC
4.65, HGB 14.8, HCT 43.3, MCV 93. - ANSWER Medical laboratory report
Identify where the following information would be found in the acute-care record: "PA and Lateral Chest:
The lungs are clear. The heart and mediastinum are normal in size and configuration. There are minor
degenerative changes of the lower thoracic spine." - ANSWER Radiography report
The ______ provided the impetus for standardizing health care records with the minimum standards
early in the twentieth century: - ANSWER ACS
The following is documented in an acute-care record: "Microscopic: Sections are of squamous mucosa
with no atypia." What would this documentation be found? - ANSWER Pathology report
The following is documented in an acute-care record: "Admit to 3C. Diet: NPO. Meds: Compazine 10 mg
IV Q 6 PRN." Where would this documentation be found? - ANSWER Admission order
The following is documented in an acute-care record: "38 weeks gestation, Apgars 8/9, 6# 9.8 oz, good
cry." Where would this documentation be found? - ANSWER Newborn record
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? - ANSWER ECG
report
, The regulations for health care record content and documentation, guidelines and regulations for which
facilities are allowed to take part in or join the Medicare and Medicaid programs is: - ANSWER Conditions
of Participation
The following is documented in an acute-care record: "Spoke to the attending re: my assessment.
Provided adoption and counseling information. Spoke to CPS re: referral. Case manager to meet with
patient and family." Where would this documentation be found? - ANSWER Social work note
Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be
used on admission of a patient to the acute care hospital in which she works. The first resource that she
should use is ______. - ANSWER UHDDS
Even though state laws may be more stringent, CMS requires acute healthcare records to be maintained
by the acute health care organization for: - ANSWER At least 5 years
A notation for diabetic patient in a physician note reads: "Occasionally gets hungry. No insulin reactions.
Says she is following her diabetic diet." Which part of a POMR progress note would this notation be
written? - ANSWER Subjective
A notation for a diabetic patient in a physician progress note reads: "FBS 100 mg%, urine sugar, no
acetone." Which part of a POMR progress note would this notation be written? - ANSWER Objective
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? - ANSWER Plan
A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood
pressure adequately controlled." Which part of a POMR progress note would this notation be written? -
ANSWER Assessment
Reviewing the health record for missing signatures and missing medical reports, and ensuring that all
documents belong in health record is an example of ______ review. - ANSWER Quantitative
and Data Content CORRECT 100%
Which of the following elements is -not- a component of most patient records? - ANSWER Financial
information
Identify where the following information would be found in the acute-care record: Following induction of
an adequate general anesthesia, and with the patient supine on the padded table, the left upper
extremity was prepped and draped in the standard fashion. - ANSWER Operative Report
Identify where the following information would be found in the acute-care record: "CBC: WBC 12.0, RBC
4.65, HGB 14.8, HCT 43.3, MCV 93. - ANSWER Medical laboratory report
Identify where the following information would be found in the acute-care record: "PA and Lateral Chest:
The lungs are clear. The heart and mediastinum are normal in size and configuration. There are minor
degenerative changes of the lower thoracic spine." - ANSWER Radiography report
The ______ provided the impetus for standardizing health care records with the minimum standards
early in the twentieth century: - ANSWER ACS
The following is documented in an acute-care record: "Microscopic: Sections are of squamous mucosa
with no atypia." What would this documentation be found? - ANSWER Pathology report
The following is documented in an acute-care record: "Admit to 3C. Diet: NPO. Meds: Compazine 10 mg
IV Q 6 PRN." Where would this documentation be found? - ANSWER Admission order
The following is documented in an acute-care record: "38 weeks gestation, Apgars 8/9, 6# 9.8 oz, good
cry." Where would this documentation be found? - ANSWER Newborn record
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? - ANSWER ECG
report
, The regulations for health care record content and documentation, guidelines and regulations for which
facilities are allowed to take part in or join the Medicare and Medicaid programs is: - ANSWER Conditions
of Participation
The following is documented in an acute-care record: "Spoke to the attending re: my assessment.
Provided adoption and counseling information. Spoke to CPS re: referral. Case manager to meet with
patient and family." Where would this documentation be found? - ANSWER Social work note
Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be
used on admission of a patient to the acute care hospital in which she works. The first resource that she
should use is ______. - ANSWER UHDDS
Even though state laws may be more stringent, CMS requires acute healthcare records to be maintained
by the acute health care organization for: - ANSWER At least 5 years
A notation for diabetic patient in a physician note reads: "Occasionally gets hungry. No insulin reactions.
Says she is following her diabetic diet." Which part of a POMR progress note would this notation be
written? - ANSWER Subjective
A notation for a diabetic patient in a physician progress note reads: "FBS 100 mg%, urine sugar, no
acetone." Which part of a POMR progress note would this notation be written? - ANSWER Objective
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? - ANSWER Plan
A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood
pressure adequately controlled." Which part of a POMR progress note would this notation be written? -
ANSWER Assessment
Reviewing the health record for missing signatures and missing medical reports, and ensuring that all
documents belong in health record is an example of ______ review. - ANSWER Quantitative
