CCA Prep Exam 2 (100 Questions)
CCA Practice Exam 2 Domain 1: Health Records and Data Content Domain 2: Health Information Requirements and Standards Domain 3: Clinical Classification Systems Domain 4: Reimbursement Methodologies Domain 5: Information and Communication Technologies Domain 6: Privacy, Confidentiality, Legal, and Ethical Issues
- 1.Documentation regarding a patient's marital status, dietary, sleep, and exercise patterns, use of coffee, tabacco, alcohol, and other drugs may be found in the _____________.
- A.
Physical examination record
- B.
History record
- C.
Operative report
- D.
Radiological report
- 2.A patient with known COPD and hypertension under treatment was admitted to the hospital with symptoms of a lower abdominal pain. He undergoes a laparoscopic appendectomy and develops a fever. The patient was subsequently discharged from the hospital with a principal diagnosis of acute appendicitis and secondary diagnoses of post-operative infection, COPD, and hypertension. Which of the following diagnoses should not be tagged as POA?
- A.
Postoperative infection
- B.
Appendicitis
- C.
COPD
- D.
Hypertension
- 3.Which of the following would not be found in a medical history?
- A.
Chief complaint
- B.
Vital signs
- C.
Present illness
- D.
Review of systems
- 4.Which of the following documentation must be included in a patient's medical record prior to performing a surgical procedure?
- A.
Consent for operative procedure, anesthesia report, surgical report
- B.
Consent for operative procedure, history, physical examination
- C.
History, physical examination, anesthesia report
- D.
Problem list, history, physical examination
- 5.Which of the following reports include names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed.
- A.
Operative report
- B.
Anesthesia report
- C.
Pathology report
- D.
Laboratory report
- 6.Identify the acute-care record report where the following information would be found: The patient is well-developed, obese male who does not appear to be in any distress, but has considerable problem with mobility. He has difficulty rising up from a chair and he uses a cane to ambulate. VITAL SIGNS: His blood pressure today is 158/86, pulse is 80 per minute, weight is 204 pounds (which is 13 pounds below what he weighed in April). He has no pallor. He has rather pronounced shaking of his arms, which he claims is not new. NECK: Showed no jugular venous distension. HEART: Very irregular. LUNGS: Clear. EXTREMITIES: Show edema of both legs.
- A.
Discharge summary
- B.
Medical history
- C.
Medical laboratory report
- D.
Physical examination
- 7.Identify the acute care record report where the following information would be found: Gross Description: Received fresh designated left lacrimal gland is a single, unoriented, irregular tan-pink portion of soft tissue measuring 0.8 x 0.6 x 0.1 cm, which is submitted entirely, intact, in one cassette.
- A.
Discharge summary
- B.
Medical history
- C.
Medical laboratory report
- D.
Physical examination
- 8.The clinical statement, "microscopic sections of the gallbladder reveals a surface lined by tall columnar cells of uniform size and shape" would be documented on which medical record form?
- A.
Operative report
- B.
Pathology report
- C.
Discharge summary
- D.
Nursing note
- 9.Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be used for ______________.
- A.
Performance improvement programs
- B.
Billing and claims data processing
- C.
Developing hospital discharge abstracting systems
- D.
Developing individual care plans for residents
- 10.What is abstracting?
- A.
Compiling the pertinent information from the medical record based on predetermined data sets
- B.
Assigning the appropriate code or nomenclature term for categorization
- C.
Assembling a chronological set of data for an express purpose
- D.
Conducting qualitative and quantitative analysis of documentation against standards and policy
- 11.What type of standard establishes uniform definitions for clinical terms?
- A.
Identifier standard
- B.
Vocabulary standard
- C.
Transaction and messaging standard
- D.
Structure and content standard
- 12.According to ICD-9-CM, an elderly primigravida is defined as a woman who gives birth to her first child at the age of ______ or older:
- A.
30
- B.
35
- C.
38
- D.
40
- 13.ICD-9-CM defines the "newborn period" as birth through the ___________ day following birth.
- A.
28th
- B.
14th
- C.
60th
- D.
30th
- 14."Late pregnancy" (category code 645) is used to demonstrate that a woman is over _______________.
- A.
41
- B.
39
- C.
40
- D.
42
- 15.Which of the following would be classified to an ICD-9-CM category for bacterial diseases?
- A.
Herpes simplex
- B.
Staphylococcus aureus
- C.
Influenza, types A and B
- D.
Candida albicans
- 16.The coder notes that the physician has presribed Retrovir for the patient. The coder might find which of the following on the patient's discharge summary?
- A.
Otitis media
- B.
AIDS
- C.
Toxic shock syndrome
- D.
Bacteremia
- 17.What diagnosis would the coder expect to see when a patient with pneumonia (PNA) has inhaled food, liquid, or oil?
- A.
Lobar pneumonia
- B.
Pneumocystitis carinii pneumonia
- C.
Interstitial pneumonia
- D.
Aspiration pneumonia
- 18.Where would a coder who needed to locate the histology of a tissue sample most likely find this information
- A.
Pathology report
- B.
Progress notes
- C.
Nurse's notes
- D.
Operative report
- 19.The coder notes the patient is taking prescribed Haldol. The final diagnoses on the progress notes include diabetes mellitus, acute pharyngitis, and malnutrition. What condition might the coder suspect the patient has and should query the physician?
- A.
Insomnia
- B.
Hypertension
- C.
Schizophrenia
- D.
Rheumatoid arthritis
- 20.Which organization developed the first hospital standardization program?
- A.
Joint Commission
- B.
American Osteopathic Association
- C.
American College of Surgeons
- D.
American Association of Medical Colleges
- 21.The hospital is revising its policy on medical record documentation. Currently, all entries in the medical record must be legible, complete, dated, and signed. The committee chairperson wants to add that, in addition, all entries must have the time noted. However, another clinician suggests that adding the time of notation is difficult and rarely may be correct since personal watches and hospital clocks may not be coordinated. Another committee member agrees and says only electronic documentation needs a time stamp. Given this discussion, which of the following might the HIM direct suggest?
- A.
Suggest that only hospital clock time be noted in clinical documentation
- B.
Suggest that only electronic documentation have time notated
- C.
Inform the committee that according to the Medicare Conditions of Participation all documentation must be authenticated and dated
- D.
Inform the committee that according to the Medicare Conditions of Participation only medication orders must include date and time
- 22.When correcting erroneous information in a health record, which of the following is not appropriate?
- A.
Print "error" above the entry
- B.
Enter the correction in chronological sequence
- C.
Add the reason for the change
- D.
Use black pen to obliterate the entry
- 23.Community Hospital implemented a clinical document improvement (CDI) program six months ago. The goal of the program was to improve clinical documentation to support quality of care, data quality, and HIM coding accuracy. Which of the following would be best to ensure that everyone understands the importance of this program?
- A.
Request that the CEO write a memorandum to all hospital staff
- B.
Give the chairperson of the CDI committee authority to fire employees who don't improve their clinical documentation
- C.
Include ancillary clinical and medical staff in the process
- D.
Request a letter from the Joint Commission
- 24.In a routine health record quantitative analysis review it was fund that a physician dictated a discharge summary on 1/26/2009. The patient, however, was discharged two days later. In this case, what would be the best course of action?
- A.
Request that the physician dictate another discharge summary
- B.
Have the record analyst note the date discrepancy
- C.
Request the physician dictate an addendum to the discharge summary
- D.
File the record as complete since the discharge summary includes all the pertinent patient information
- 25.During an audit of health records, the HIM director finds that transcribed reports are being changed by the author up to a week after initial transcription. The director is concerned that changes occurring this long after transcription jeopardize the legal principle that documentation must occur near the time of the event. To remedy this situation, the HIM director should recommend which of the following?
- A.
Immediately stop the practice of changing transcribed reports
- B.
Develop a facility policy that defines the acceptable period of time allowed for a transcribed document to remain in draft form
- C.
Conduct a verification audit
- D.
Alert hospital legal counsel of the practice
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