CCS Exam Prep Health Data Content and Standards
A
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.
A
74. Engaging patients and their families in health care decisions is one of the core objectives for A. achieving meaningful use of EHRs. B. Joint Commission's National Patient Safety goals. C. HIPAA 5010 regulations. D. establishing flexible clinical pathways.
B
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.
A
19. Which of the following is a form or view that is typically seen in the health record of a long-term care patient but is rarely seen in records of acute care patients? A. pharmacy consultation C. physical exam B. medical consultation D. emergency record
C
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.
D
11. The performance of qualitative analysis is an important tool in ensuring data quality. These reviews evaluate A. quality of care through the use of preestablished criteria. B. adverse effects and contraindications of drugs utilized during hospitalization. C. potentially compensable events. D. the overall quality of documentation.
B
12. Ultimate responsibility for the quality and completion of entries in patient health records belongs to the A. chief of staff. C. HIM director. B. attending physician. D. risk manager.
C
13. The foundation for communicating all patient care goals in long-term care settings is the A. legal assessment. C. interdisciplinary plan of care. B. medical history. D. Uniform Hospital Discharge Data Set.
C
14. As part of Joint Commission's National Patient Safety Goal initiative, acute care hospitals are now required to use a preoperative verification process to confirm the patient's true identity and to confirm that necessary documents such as X-rays or medical records are available. They must also develop and use a process for A. including the primary caregiver in surgery consults. B. including the surgeon in the preanesthesia assessment. C. marking the surgical site. D. apprising the patient of all complications that might occur.
A
15. Currently, the enforcement of HIPAA Privacy and Security Rules is the responsibility of the A. Office for Civil Rights. B. FBI. C. Office of Inspector General. D. Department of Recovery Audit Coordinators.
A
16. Using the SOAP method of recording progress notes, which entry would most likely include a differential diagnosis? A. assessment B. plan C. subjective D. objective
D
17. You have been asked by a peer review committee to print a list of the medical record numbers of all patients who had CABGs performed in the past year at your acute care hospital. Which secondary data source could be used to quickly gather this information? A. disease index C. master patient index B. physician index D. operation index
D
18. The best example of point-of-care service and documentation is A. using an automated tracking system to locate a record. B. using occurrence screens to identify adverse events. C. doctors using voice recognition systems to dictate radiology reports. D. nurses using bedside terminals to record vital signs.
B
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.
D
20. In determining your acute care facility's degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is the A. CARF manual. C. Joint Commission accreditation manual. B. hospital bylaws. D. Federal Register.
D
21. In an acute care hospital, a complete history and physical may not be required for a new admission when A. the patient is readmitted for a similar problem within 1 year. B. the patient's stay is less than 24 hours. C. the patient has an uneventful course in the hospital. D. a legible copy of a recent H&P performed in the attending physician's office is available.
A
22. When developing a data collection system, the most effective approach first considers A. the end user's needs. C. hardware requirements. B. applicable accreditation standards. D. facility preference.
C
23. A key data item you would expect to find recorded on an ER record but would probably NOT see in an acute care record is the A. physical findings. C. time and means of arrival. B. lab and diagnostic test results. D. instructions for follow-up care.
B
24. Under which of the following conditions can an original paper-based patient health record be physically removed from the hospital? A. when the patient is brought to the hospital emergency department following a motor vehicle accident and, after assessment, is transferred with his health record to a trauma designated emergency department at another hospital B. when the director of health records is acting in response to a subpoena duces tecum and takes the health record to court C. when the patient is discharged by the physician and at the time of discharge is transported to a long-term care facility with his health record D. when the record is taken to a physician's private office for a follow-up patient visit postdischarge
D
25. Using the SOAP style of documenting progress notes, choose the "subjective" statement from the following. A. sciatica unimproved with hot pack therapy B. patient moving about very cautiously, appears to be in pain C. adjust pain medication; begin physical therapy tomorrow D. patient states low back pain is as severe as it was on admission
B
26. In 1987, OBRA helped shift the focus in long-term care to patient outcomes. As a result, core assessment data elements are collected on each SNF resident as defined in the A. UHDDS. C. Uniform Clinical Data Set. B. MDS. D. Uniform Ambulatory Core Data.
A
27. Before you submit a new form to the Forms Review Committee, you need to track the field name of a particular data field and the security levels applicable to that field. Your best source for this information would be the A. facility's data dictionary. C. Glossary of Health Care Terms. B. MDS. D. UHDDS.
B
28. You notice on the admission H&P that Mr. McKahan, a Medicare patient, was admitted for disc surgery, but the progress notes indicate that due to some heart irregularities, he may not be at good surgical risk. Because of your knowledge of COP regulations, you expect that a(n) will be added to his health record. A. interval summary C. advance directive B. consultation report D. interdisciplinary care plan
B
29. An example of objective entry in the health record supplied by a health care practitioner is the A. past medical history. C. chief complaint. B. physical assessment. D. review of systems.
C
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.
B
75. Where in the health record would the following statement be located? "Microscopic Diagnosis: Liver (needle biopsy), metastatic adenocarcinoma" A. operative report C. anesthesia report B. pathology report D. radiology report
D
30. You have been asked to recommend time-limited documentation standards for inclusion in the Medical Staff Bylaws, Rules, and Regulations. The committee documentation standards must meet the standards of both the Joint Commission and the Medicare Conditions of Participation. The standards for the history and physical exam documentation are discussed first. You advise them that the time period for completion of this report should be set at A. 12 hours after admission. B. 24 hours after admission. C. 12 hours after admission or prior to surgery. D. 24 hours after admission or prior to surgery.
B
31. Based on the following documentation in an acute care record, where would you expect this excerpt to appear? "With the patient in the supine position, the right side of the neck was appropriately prepped with betadine solution and draped. I was able to pass the central line which was taped to skin and used for administration of drugs during resuscitation." A. physician progress notes B. operative record C. nursing progress notes D. physical examination
A
32. One essential item to be captured on the physical exam is the A. general appearance as assessed by the physician. B. chief complaint. C. family history as related by the patient. D. subjective review of systems. REFERENCE: Abdelhak and Hanken, p 105
D
33. An example of a primary data source for health care statistics is the A. disease index. C. MPI. B. accession register. D. hospital census.
D
34. During a retrospective review of Rose Hunter's inpatient health record, the health information clerk notes that on day 4 of hospitalization there was one missed dose of insulin. What type of review is this clerk performing? A. utilization review C. legal review B. quantitative review D. qualitative review
C
35. Which of the following is least likely to be identified by a deficiency analysis technician? A. missing discharge summary B. need for physician authentication of two verbal orders C. discrepancy between post-op diagnosis by the surgeon and pathology diagnosis by the pathologist D. X-ray report charted on the wrong record
B
36. Which of the following reports would normally be considered a consultation? A. tissue examination done by the pathologist B. impressions of a cardiologist asked to determine whether patient is at good surgical risk C. interpretation of a radiologic study D. technical interpretation of electrocardiogram
A
37. The health care providers at your hospital do a very thorough job of periodic open record review to ensure the completeness of record documentation. A qualitative review of surgical records would likely include checking for documentation regarding A. the presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed. B. whether a postoperative infection occurred and how it was treated. C. the quality of follow-up care. D. whether the severity of illness and/or intensity of service warranted acute level care.
A
38. In your facility, the health care providers from every discipline document progress notes sequentially on the same form. Your facility is utilizing A. integrated progress notes. C. source-oriented records. B. interdisciplinary treatment plans. D. SOAP notes.
B
39. Which of the following services is LEAST likely to be provided by a facility accredited by CARF? A. chronic pain management C. brain injury management B. palliative care D. vocational evaluation
C
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.
C
40. Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of A. peer review. C. qualitative review. B. quantitative review. D. legal analysis.
D
41. Accreditation by Joint Commission is a voluntary activity for a facility and it is A. considered unnecessary by most health care facilities. B. required for state licensure in all states. C. conducted in each facility annually. D. required for reimbursement of certain patient groups.
D
42. Which of the following indices might be protected from unauthorized access through the use of unique identifier codes assigned to members of the medical staff? A. disease index C. master patient index B. procedure index D. physician index
B
43. Which of the four distinct components of the problem-oriented record serves to help index documentation throughout the record? A. database C. initial plan B. problem list D. progress notes
C
44. You have been asked to report the registry's annual caseload to administration. The most efficient way to retrieve this information would be to use A. patient abstracts. C. accession register. B. patient index. D. follow-up files.
A
45. Based on the following documentation in an acute care record, where would you expect this excerpt to appear? "Initially the patient was admitted to the medical unit to evaluate the x-ray findings and the rub. He was started on Levaquin 500 mg initially and then 250 mg daily. The patient was hydrated with IV fluids and remained afebrile. Serial cardiac enzymes were done. The rub, chest pain, and shortness of breath resolved. EKGs remained unchanged. Patient will be discharged and followed as an outpatient." A. discharge summary B. physical exam C. admission note D. clinical laboratory report
D
46. The best resource for checking out specific voluntary accreditation standards and guidelines for a rehabilitation facility is the A. Conditions of Participation for Rehabilitation Facilities. B. Medical Staff Bylaws, Rules, and Regulations. C. Joint Commission manual. D. CARF manual.
A
47. Stage I of meaningful use focuses on data capture and sharing. Which of the following is included in the menu set of objectives for eligible hospitals in this stage? A. use CPOE for medication orders B. smoking cessation counseling for MI patients C. appropriate use of HL-7 standards D. establish critical pathways for complex, high-dollar cases
A
48. Which of the following is a secondary data source that would be used to quickly gather the health records of all juvenile patients treated for diabetes within the past 6 months? A. disease index C. pediatric census sheet B. patient register D. procedure index
D
49. Your job description includes working with agents who have been charged with detecting and correcting overpayments made to your hospital in the Medicare Fee for Service program. You will need to develop a professional relationship with A. the OIG. C. QIO physicians. B. MEDPAR representatives. D. recovery audit contractors.
D
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
50. A primary focus of screen format design in a health record computer application should be to ensure that A. programmers develop standard screen formats for all hospitals. B. the user is capturing essential data elements. C. paper forms are easily converted to computer forms. D. data fields can be randomly accessed.
B
51. Before making recommendations to the Executive Committee regarding new physicians who have applied for active membership, the Credentials Committee must query the A. peer review organization. B. National Practitioner Data Bank. C. risk manager. D. Health Plan Employer Data and Information Set.
D
52. The lack of a discharge order may indicate that the patient left against medical advice. If this situation occurs, you would expect to see the circumstances of the leave A. documented in an incident report and filed in the patient's health record. B. reported as a potentially compensable event. C. reported to the Executive Committee. D. documented in both the progress notes and the discharge summary.
C
53. You recommend that the staff routinely check to verify that a summary on each patient is provided to the attending physician so that he or she can review, update, and recertify the patient as appropriate. The time frame for requiring this summary is at least every A. week. C. 60 days. B. month. D. 90 days.
D
54. You want to review the one document in your facility that will spell out the documentation requirements for patient records; designate the time frame for completion by the active medical staff; and indicate the penalties for failure to comply with these record standards. Your best resource will be A. medical staff bylaws. B. quality management plan. C. Joint Commission accreditation manual. D. medical staff rules and regulations.
C
55. For inpatients, the first data item collected of a clinical nature is usually A. principal diagnosis. C. admitting diagnosis. B. expected payer. D. review of systems.
D
56. In addition to diagnostic and therapeutic orders from the attending physician, you would expect every completed inpatient health record to contain A. standing orders. C. stop orders. B. telephone orders. D. discharge order.
D
57. When asked to explain how "review of systems" differs from "physical exam," you explain that the review of systems is used to document A. objective symptoms observed by the physician. B. past and current activities, such as smoking and drinking habits. C. a chronological description of patient's present condition from time of onset to present. D. subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant.
A
58. Based on the following documentation, where would you expect this excerpt to appear? "The patient is alert and in no acute distress. Initial vital signs: T98, P 102 and regular, R 20 and BP 120/69..." A. physical exam B. past medical history C. social history D. chief complaint
B
59. The federally mandated resident assessment instrument used in long-term care facilities consists of three basic components, including the new care area assessment, utilization guidelines, and the A. UHDDS. C. OASIS. B. MDS. D. DEEDS.
B
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.
C
60. You recommend that the staff at your home health agency routinely check to verify that a summary on each patient is provided to the attending physician so that he or she can review, update, and recertify the patient as appropriate. The time frame for requiring this summary is at least every A. week. C. 60 days. B. month. D. 90 days.
A
61. To enter the results of a CBC into the computer system, you would use a(n) A. laboratory system. C. pharmacy system. B. radiology system. D. order entry/results reporting system.
D
62. Which of the following would not be an example of a secondary data source? A. disease index C. MPI B. accession register D. hospital census
D
63. The Recovery Audit Contractor (RAC) program was developed to identify and reduce improper payments for A. Medicaid claims. B. Medicare claims. C. both Medicare claims and collection of overpayments. D. collection of overpayments.
A
64. You have been asked to give an example of a clinical information system. Which one of the following would you cite? A. laboratory information system C. billing system B. financial information system D. admission-discharge-transfer
D
65. The PQRS is a reporting system established by the federal government for physician practices that participate in Medicare for A. monetary incentives. B. meaningful use incentives. C. quality measure reporting. D. All answers apply.
B
66. Surgical case review includes all of the following EXCEPT A. determination of surgical justification based on clinical indication(s) in cases where no tissue has been removed. B. cases with elements missing in the preoperative anesthesia consultation. C. cases where there is a significant discrepancy between preoperative, postoperative, and pathological diagnoses. D. cases with serious surgical complications or surgical mortalities.
D
67. While performing routine quantitative analysis of a record, a medical record employee finds an incident report in the record. The employee brings this to the attention of her supervisor. Which best practice should the supervisor follow to deal with this situation? A. Remove the incident report and send it to the patient. B. Tell the employee to leave the report in the record. C. Remove the incident report and have nursing personnel transfer all documentation from the report to the medical record. D. Refer this record to the Risk Manager for further review and removal of the incident report.
A
68. In compiling statistics to report the specific cause of death for all open-heart surgery cases, the quality coordinator assists in documenting A. patient care outcomes. B. utilization of hospital resources. C. delineation of physician privileges. D. compliance with OSHA standards.
C
69. Your hospital is required by the Joint Commission and CMS to participate in national benchmarking on specific disease entities for quality of care measurement. This required collection and reporting of disease-specific data is considered A. an environment of care. B. a group of sentinel events. C. a series of core measures. D. risk assessment.
A
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
70. Needlesticks, patient or employee falls, medication errors, or any event not consistent with routine patient care activities would require risk reporting documentation in the form of an A. operative report. C. incident report. B. emergency room report. D. insurance claim.
D
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
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
C
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
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.
