CCS Exam Prep Health Data Content and Standards, Questions and answers, 100% Accurate, rated A+

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CCS Exam Prep Health Data Content and Standards, Questions and answers, 100% Accurate, rated A+ B - ✔✔-1. In preparation for an EHR, you are working with a team conducting a total facility in... ventory 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 - ✔✔-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 - ✔✔-3. In the past, Joint Commission standards have focused on promoting the use of a facilityapproved 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 - ✔✔-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 - ✔✔-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 - ✔✔-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 - ✔✔-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 - ✔✔-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. 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. A - ✔✔-19. Which of the following is a form or view that is typically seen in the health record of a longterm care patient but is rarely seen in records of acute care patients? A. pharmacy consultation C. physical exam B. medical consultation D. emergency record 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 t [Show More]

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