CCS EXAM QUESTIONS AND ANSWERS

For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the interdisciplinary patient care plan. discharge summary. transfer record.For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the interdisciplinary patient care plan. problem list. discharge summary. transfer record. - Answer- Discharge summary documentation must include correct codes for significant procedures. a note from social services or discharge planning. significant findings during hospitalization. a detailed history of the patient. - Answer-significant findings during hospitalization. Some reference to the patient's history may be found in the discharge summary but not a detailed history. The attending physician rather than a social worker records the discharge summary. Procedure codes are usually recorded on a different form in the record. In preparation for an EHR, you are 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 operative report. discharge summary. pathology