CCA study guide.docx - 1 Discharge summary documentation...

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1. Discharge summary documentation must include: significant findings during hospitalization. 2. 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. 3. You have been asked to identify every reportable case of cancer from the previous year. A key resource will be the facility's disease index. 4. Joint Commission does not approve auto authentication of entries in a health record. The primary objection to this practice is that tampering too often occurs with this method of authentication. 5. One of the patients at your physician group practice has asked for an electronic copy of her medical record. Your electronic computer system will not allow you to accommodate this request. Chances are, you are NOT in compliance with the HIPAA Privacy Rule. 6. 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 use of prohibited or "dangerous" abbreviations.
7. One of the Joint Commission National Patient Safety Goals (NSPGs) requires that health care organizations eliminate wrong-site, wrong-patient, and wrong-procedure surgery. In order to accomplish this, which of the following would NOT be considered part of a preoperative verification process? Follow the daily surgical patient listing for the surgery suite if the patient has been sedated. 8. 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 incident report. 9. A qualitative review of a health record reveals that the history and physical for a patient admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the following statements regarding the history and physical is true in this situation? Completion and charting of the H&P indicates noncompliance with Joint Commission standards. 10. 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 prenatal record. 11. 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 cognitive patterns.

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