CCA EXAM DOMAIN 3 WITH
QUESTIONS AND 100% CORRECT
ANSWERS ALREADY PASSED!!!
1. Which of the following elements is not a component of most patient records?
A. Patient identification
B. Clinical history
C. Financial information
D. Test results
Answer: C. Financial information
2. Identify where the following information would be found in an acute care record:
"Following induction of an adequate general anesthesia, and with the patient supine on the
padded table, the left upper extremity was prepped and draped in the standard fashion."
A. Anesthesia report
B. Physician progress notes
C. Operative Report
D. Recovery room record
Answer: C. Operative report
3. Identify where the following information would be found in the acute care record:
"CBC, WBC 12.0, RBC 4.65, HGB 14.8, MCV 93?"
A. Medical laboratory report
B. Pathology report
C. Physical examination
D. Physician orders
Answer: A. Medical laboratory report
4. Identify where the following information would be found in the acute care record: "PA
and lateral chest, the lungs are clear. The heart and mediastinum are normal in size and
configuration. There are minor degenerative changes of the lower thoracic spine."
,A. Medical laboratory report
B. Physical examination
C. Physician progress note
D. Radiography report
Answer: D. Radiography report
5. The ____ provided the impetus for standardizing health care records with minimum
standards early in the twentieth century?
Answer: ACS
6. The following is documented in an acute care record: "Microscopic sections are of
squamous mucous with no atypia." Where would this documentation be found?
A. History
B. Pathology report
C. Physical Examination
D. Operative Report
Answer: B. Pathology report
7. The following is documented in an acute-care record: "Admit to 3C. Diet: NPO. Meds:
Compazine 10 mg IV Q 6 PRN." In which of the following would this documentation
appear?
A. Admission order
B. History
C. Physical examination
D. Progress notes
Answer: A. Admission order
8. The following is documented in an acute care record: "38 weeks of gestation, Apgars 8/9,
6# 9.8oz, good cry." Where would this documentation be found?
A. Admission note
B. Clinical laboratory
C. Newborn record
D. Physician order
, Answer: C. Newborn record
9. The following is documented in an acute care record: "Atrial fibrillation with rapid
ventricular response, left axis deviation, left bundle branch block." Where would this
documentation be found?
A. Admission order
B. Clinical laboratory report
C. ECG report
D. Radiology report
Answer: C. ECG report
10. The regulation for health care record content and documentation, guidelines and
regulations for which facilities are allowed to take part or join the Medicare and Medicaid
programs is?
A. Medical staff bylaws
B. Conditions of participation
C. Joint commission rules
D. American college of surgeon regulations
Answer: B. Conditions of participation
11. The following is documented in an acute care record: "Spoke to the attending, my
assessment provided adoption and counseling information. Spoke to CPS referral. Case
manager to meet with patient or family." Where would this documentation be found?
A. Admission note
B. Nursing note
C. Physician progress note
D. Social work note
Answer: D. Social work note
12. Mary Smith, RHIA, has been charged with the responsibility of designing a data
collection form to be used on admission of a patient to the acute care hospital in which she
works. The first resource that she should use is ______.
A. UHDDS
B. UACDS
QUESTIONS AND 100% CORRECT
ANSWERS ALREADY PASSED!!!
1. Which of the following elements is not a component of most patient records?
A. Patient identification
B. Clinical history
C. Financial information
D. Test results
Answer: C. Financial information
2. Identify where the following information would be found in an acute care record:
"Following induction of an adequate general anesthesia, and with the patient supine on the
padded table, the left upper extremity was prepped and draped in the standard fashion."
A. Anesthesia report
B. Physician progress notes
C. Operative Report
D. Recovery room record
Answer: C. Operative report
3. Identify where the following information would be found in the acute care record:
"CBC, WBC 12.0, RBC 4.65, HGB 14.8, MCV 93?"
A. Medical laboratory report
B. Pathology report
C. Physical examination
D. Physician orders
Answer: A. Medical laboratory report
4. Identify where the following information would be found in the acute care record: "PA
and lateral chest, the lungs are clear. The heart and mediastinum are normal in size and
configuration. There are minor degenerative changes of the lower thoracic spine."
,A. Medical laboratory report
B. Physical examination
C. Physician progress note
D. Radiography report
Answer: D. Radiography report
5. The ____ provided the impetus for standardizing health care records with minimum
standards early in the twentieth century?
Answer: ACS
6. The following is documented in an acute care record: "Microscopic sections are of
squamous mucous with no atypia." Where would this documentation be found?
A. History
B. Pathology report
C. Physical Examination
D. Operative Report
Answer: B. Pathology report
7. The following is documented in an acute-care record: "Admit to 3C. Diet: NPO. Meds:
Compazine 10 mg IV Q 6 PRN." In which of the following would this documentation
appear?
A. Admission order
B. History
C. Physical examination
D. Progress notes
Answer: A. Admission order
8. The following is documented in an acute care record: "38 weeks of gestation, Apgars 8/9,
6# 9.8oz, good cry." Where would this documentation be found?
A. Admission note
B. Clinical laboratory
C. Newborn record
D. Physician order
, Answer: C. Newborn record
9. The following is documented in an acute care record: "Atrial fibrillation with rapid
ventricular response, left axis deviation, left bundle branch block." Where would this
documentation be found?
A. Admission order
B. Clinical laboratory report
C. ECG report
D. Radiology report
Answer: C. ECG report
10. The regulation for health care record content and documentation, guidelines and
regulations for which facilities are allowed to take part or join the Medicare and Medicaid
programs is?
A. Medical staff bylaws
B. Conditions of participation
C. Joint commission rules
D. American college of surgeon regulations
Answer: B. Conditions of participation
11. The following is documented in an acute care record: "Spoke to the attending, my
assessment provided adoption and counseling information. Spoke to CPS referral. Case
manager to meet with patient or family." Where would this documentation be found?
A. Admission note
B. Nursing note
C. Physician progress note
D. Social work note
Answer: D. Social work note
12. Mary Smith, RHIA, has been charged with the responsibility of designing a data
collection form to be used on admission of a patient to the acute care hospital in which she
works. The first resource that she should use is ______.
A. UHDDS
B. UACDS
