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CCS EXAM PREP EXAM PRACTICE
VERIFIED QUESTIONS AND CORRECT
ANSWERS 2025/2026.
Impaired Glucose Tolerence - Correct Answer>>Dx given to people who have blood sugar levels higher than normal but not enough to be given the dx of diabetes Brittle Diabetic - Correct Answer>>Blood sugars quickly swing from high to low and from low to high (unstable) Extrinsic Asthma - Correct Answer>>patients with this type of asthma have a family hx of asthma Review Of Systems - Correct Answer>>Physician asks patient a series of questions about how they feel. Usually organized by body system The physician does not touch the patient during ROS Impression - Correct Answer>>Physicians opinion on what is wrong with the patient (admitting dx) Timing of H&P - Correct Answer>>Must be documented within 24hrs of admission Must be documented before surgery Can be documented no more than 7 days prior to admission If pt is readmitted within 30 days for the same condition the physician may use an "interval note"
Standing Orders - Correct Answer>>Orders established by a physician that apply to a particular dx or condition Verbal Orders - Correct Answer>>Usually by telephone According to Medicare Conditions Of Participation state verbal order should be authenticated within 48 hrs Discharge Orders - Correct Answer>>Written at time physician decides patient is ready to go home or be transferred to another facility Clinical Information - Correct Answer>>Medical Hx Dx Theraputic Orders Observations Purpose of Uniform Healthcare Data Sets - Correct Answer>>Ensure data collection for every patient is consistent Enables comparison of health care data on a national level for analysis Interval Note - Correct Answer>>Info about pt current complaint Any relevant changes in condition Physical Findings since last admission Progress Note - Correct Answer>>Chronological record of the clinical observations of the pt condition and response to treatment during the hospital stay Supports medical necessity Written every 1 to 2 days
uncomplicated delivery of an infant (moms record) normal newborn infant (baby's record) Autopsy Report Timeliness - Correct Answer>>Provisional Autopsy Record- within 3 days of autopsy Final Autopsy Record- within 60 days after completion Gravida - Correct Answer>>number of pregnancies Para - Correct Answer>>number of deliveries of viable infants VDRL - Correct Answer>>Venereal Disease Research Lab Lochia
- Correct Answer>>discharge of blood from the uterus after birth Secundices - Correct Answer>>placenta and membranes extruded after birth EMTALA - Correct Answer>>Emergency Medical Treatment and Active Labor Act Prohibits the transferring of uninsured patients to public hospitals to avoid treating them Occupational Therapy - Correct Answer>>restores pt ability to perform daily activities of living (self care activities) Recreational Therapy - Correct Answer>>restores pt ability to enhance independent living skills through recreational opportunities Source Oriented Health Records - Correct Answer>>Documents grouped together according to department they originated, then arranged in chronological (or reverse Chronological) order
Problem Oriented Health Records - Correct Answer>>Arranged according to a problem list Problem List - Correct Answer>>Listing of patients past and present social,psychological, and medical problems. Each problem indexed with a unique number Reports/documentation reference the # of the problem they address 4 components of a problem-oriented health record - Correct Answer>>Problem List Database (contains CC,present illness,social/med hx,physical exam,test results) Initial Care Plan Progress Notes SOAP notes - Correct Answer>>Format of progress notes Subjective (what patient tells Dr) Objective (what Dr observes) Assessment Plan Medicare Conditions Of Participation - Correct Answer>>Includes standards for health record content,confidentiality, and retention Published under the Code Of Federal Regulations (CFR-42) Federal Register - Correct Answer>>A daily legal newspaper, which publishes final changes/updates to the Code Of Federal Regulations
may extend down to, but not through, underlying fascia. Stage IV Decubitus Ulcer - Correct Answer>>Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Early Fetal Death - Correct Answer>>Less than 20 weeks gestation or wt of 500g or less Intermediate Fetal Death - Correct Answer>> 20 - less than 28 weeks gestation or a wt of 501-1000g Late Fetal Death - Correct Answer>>28 weeks gestation or a wt of more than 1000g Direct Maternal Death - Correct Answer>>Death of a woman resulting from OB complications of the pregnancy,labor or puerperium (birth-6 weeks after delivery) Indirect Maternal Death - Correct Answer>>Death of a woman from a previously existing disease that developed during pregnancy,labor or the puerperium that was not due to obstetric causes but although the physiologic effects of pregnancy were partially responsible for the death Joint Commission States that the gross autopsy report be completed in how many days? - Correct Answer>>3 days Joint Commission States that the microscopic autopsy report be completed in how many days? - Correct Answer>>60 days Mean - Correct Answer>>Average Median - Correct Answer>>Middle number Arrange numbers in numerical order
Mode - Correct Answer>>The value that occurs most frequently Range - Correct Answer>>Largest value-Smallest value How do you get the median in an even number of values? - Correct Answer>>Add the 2 middle values and divide by 2 If the Standard Deviation is.........there is less dispersion around the mean. - Correct Answer>>Small If the Standard Deviation is.........there is more dispersion around the mean. - Correct Answer>>Large Normal Distribution of Data - Correct Answer>>*Most values in a set of data are close to the average Relatively few values tend to one extreme or the other, creating a Bell Shaped Curve Skewed to the right - Correct Answer>>The longer tail is on the right p 186 Skewed to the left - Correct Answer>>The longer tail is on the left p 186 Discrete Data - Correct Answer>>Can only have specified values *An exact number/not a fraction Ex. Number of children in a family Continuous Data - Correct Answer>>Not restricted to certain specified values *Can be a fraction *Ex. Temperature 102.6, Height Graphs should be greater in............... - Correct Answer>>length than height Horizontal Axis is............ - Correct Answer>>left to right
entries,progress note dated prior to admission etc Quality of records Does documentation reflect the quality of patient care provided Incident Report - Correct Answer>>Written accounts of unusual events that have an adverse effect on a patient, employee, or facility visitor. Never filed in patient health record. Used by risk management and or attorney to investigate incidents that have the potential to become claims against the organization or individual provider. Incident - Correct Answer>>An event considered to be inconsistent with accepted standards of care. Ex. res ipsa loquitor - Correct Answer>>"the thing speaks for itself" The injury would not ordinarily occur without someones negligence Ex. Surgical instrument left in patient after surgery Currency - Correct Answer>>... Data Accessibility - Correct Answer>>data is available to those authorized to use it Relevancy - Correct Answer>>... Consistency - Correct Answer>>... Benchmarking - Correct Answer>>Process of comparing an organization to a standard, a peer group, or other organization. Ex. A hospital may want to compare its ALOS (average length of stay) with the ALOS for all hospitals nationwide.
Continuum Of Care - Correct Answer>>Various types of healthcare services provided in diverse settings from basic primary care to complex tertiary settings. Primary Care - Correct Answer>>Services provided by physicians working in private offices, group practices, private clinics or community based clinics. Ex Family practice, pediatrics Ex of primary care services: preventative,routine screening,physical exams Secondary Care - Correct Answer>>Diagnostic and theraputic services provided by medical specialists. Tertiary Care - Correct Answer>>The provision of highly specialized and advanced diagnostic and therapeutic services in inpatient hospital settings. The medical record is the property of the ........ - Correct Answer>>facility/institution The information in the medical record is owned by the..... - Correct Answer>>patient Legal Health record - Correct Answer>>Official business record of the healthcare orginization Derived Data - Correct Answer>>Health information collected from health records No patient identifiers Data - Correct Answer>>Raw facts and figures expressed in test, numbers symbols and figures
Disease Index - Correct Answer>>Categorizes patient encounters by diagnosis Arranged by diagnosis codes Clinical Data - Correct Answer>>data related to the patients medical status and treatment Medical record is the primary source of clinical data Data Sets - Correct Answer>>particular data elements that are to be routinely collected EMDS - Correct Answer>>data elements to help practitioners improve the quality of care during emergency encounters Data Validity - Correct Answer>>numbers, characters, or symbols stored, processed and displayed are exact and conform to known standards (correctness of data) Ex. ICD-9CM code 250 (this code is not valid as it needs additional digits) Data Reliability - Correct Answer>>data that is the same no matter who collected it or how many times it is collected Ex. reliable data is consistent when entered into 2 or more databases Data Completeness - Correct Answer>>All required data points are present Ex. birthdate 1/31, this is not complete because the yesr is missing Current Data - Correct Answer>>data is recorded at or near the time of observation
Data Timeliness - Correct Answer>>the period of time between recording or producing the data element and making the information available to users is short. Data usefulness/meaningful - Correct Answer>>data must be relevant and understandable Ex. the abbrev LOC appeared in a progress note, does it mean "laxitive of choice" or "loss of consciousness" Principle Dx - Correct Answer>>The condition established after study to be chiefly responsible for admission of the patient to the hospital Explains the reason the patient was admitted to the hospital Secondary Dx - Correct Answer>>All conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or length of stay. Include comorbidities and complications Comorbidity - Correct Answer>>Any condition that coexists during the relevant episode of car and EFFECTS THE TREATMENT PROVIDED TO THE PATIENT (what patient comes in the door with) pre-exisiting condition that will affect treatment or increase the patients length of stay Complication - Correct Answer>>Any condition that arises during the relevant episode of care and EFFECTS THE TREATMENT PROVIDED TO THE PATIENT
Ultralente Humalog Novolin Lenti Lantus Adult On set Diabetes - Correct Answer>>Type 2 Diabetes Formerly known as NIDDM (non insulin dependent diabetes mellitus) Insulin Requiring Diabetes Patient is not dependent on insulin to live Prone to develop dehydration Insulinopenia - Correct Answer>>abscence of insulin production
