Ahima CCA Help For Exam Updated 2023-2024/98
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Quiz :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
a.)Pathology b.) operative report c.)discharge summary d.) recovery room record -
Answer :Pathology report
Quiz :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. cognitive patterns.
b. procedures and dates.
c. principal diagnosis.
d. personal identification. - Answer :cognitive patterns
Quiz :.
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. flagrant use of specialty-specific abbreviations.
b. use of prohibited or "dangerous" abbreviations.
c. prohibited use of any abbreviations.
d. use of abbreviations in the final diagnosis. - Answer :Use of prohibited of
"dangerous"abbreviations
, Quiz :Engaging patients and their families in health care decisions is one of the
core objectives for
a. the Joint Commission's National Patient Safety goals.
b. HIPAA 5010 regulations.
c. achieving meaningful use of EHRs.
d. establishing flexible clinical pathways. - Answer :Achieving meaningful use of
EHR's
Quiz :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. integrated progress notes.
b. incident report.
c. doctors' progress notes.
d. nurses' notes. - Answer :incident report
Quiz :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. discharge summary.
b. transfer record.
c. interdisciplinary patient care plan.
d. problem list. - Answer :problem list
Quiz :Joint Commission does not approve of auto authentication of entries in a
health record. The primary objection to this practice is that
a. evidence cannot be provided that the physician actually reviewed and
approved each report.
b. electronic signatures are not acceptable in every state.
c. it is too easy to delegate use of computer passwords.
d. tampering too often occurs with this method of authentication. -
Answer :evidence cannot be provided that the physician actually reviewed and
approved each report
, Quiz :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. labor and delivery record.
b. postpartum record.
c. prenatal record.
d. discharge summary. - Answer :prenatal record
Quiz :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. that you apologize for not noticing the H&P she provided.
b. the H&P copy is acceptable as long as she documents any interval changes.
c. a new H&P is required for every inpatient admission.
d. Joint Commission standards do not allow copies of any kind in the original
record. - Answer :the h&p is acceptable as long as she doc any interval change
Quiz :You have been asked to identify every reportable case of cancer from the
previous year. A key resource will be the facility's
a. number control index.
b. physicians' index.
c. disease index.
d. patient index. - Answer :disease index
Quiz :Joint Commission requires the attending physician to countersign health
record documentation that is entered by
a. business associates.
b. consulting physicians.
c. interns or medical students.
d. physician partners. - Answer :interns or medical student
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