CCA Health Records & Data Content Practice Questions
Health Records & Data Content makes up 7 of every 50 questions on a Tigertest CCA practice test. Here are 10 of the 28 questions on it, each with the answer and the reason.
Updated by the Tigertest team. Weighted to the AHIMA CCA Exam Content Outline. Original questions on coding guidelines and concepts; not affiliated with AHIMA.
1. Which document summarizes an inpatient stay, including the final diagnoses and condition at discharge?
- A.Consultation report
- B.Discharge summary
- C.History and physical
- D.Daily progress note
Answer: B. The discharge summary recaps the reason for admission, significant findings, procedures, final diagnoses and the condition at discharge. The history and physical is written at admission, not at the end of the stay.
2. Which item is a required element of an operative report?
- A.Discharge instructions for home
- B.Patient's insurance plan details
- C.Admitting vital signs
- D.Findings and specimens removed
Answer: D. An operative report names the surgeon and assistants and records the procedure, findings, estimated blood loss, specimens removed and the postoperative diagnosis. Discharge instructions belong elsewhere in the record.
3. Which report describes the gross and microscopic examination of tissue removed in surgery?
- A.Pathology report
- B.Radiology report
- C.Operative report
- D.Anesthesia record
Answer: A. The pathologist's report gives the gross and microscopic description and the tissue diagnosis. The operative report describes the procedure itself, not the lab examination of the specimen.
4. Which document records each drug dose given to a patient, with the time and route?
- A.Medication reconciliation form
- B.Pharmacy medication dispensing log
- C.Medication administration record
- D.Physician order sheet
Answer: C. Nurses document every dose given, with time, route and initials, on the MAR. The order sheet shows what was prescribed, not what was actually given.
5. A specialist's findings and recommendations, requested by the attending physician, are documented in the:
- A.History and physical
- B.Discharge summary
- C.Consultation report
- D.Progress notes
Answer: C. A consultation report records the consultant's opinion and recommendations at the attending physician's request. Progress notes track the patient's course day to day.
6. Before surgery, the record must show the patient agreed after learning the risks, benefits and alternatives. This document is the:
- A.Informed consent
- B.Notice of privacy practices
- C.Release of information
- D.Advance directive
Answer: A. Informed consent shows the patient was told the risks, benefits and alternatives and agreed. An advance directive states wishes for future care if the patient cannot decide.
7. A living will and a durable power of attorney for health care are types of:
- A.Physician orders
- B.Informed consents
- C.Authorizations
- D.Advance directives
Answer: D. Advance directives state a patient's wishes, or name a decision maker, for care when the patient cannot speak for themselves. The Patient Self-Determination Act requires facilities to ask about them at admission.
8. For an inpatient record, a radiology report shows pneumonia, but no provider documents it. The best action is to:
- A.Leave it off without asking
- B.Query the attending physician
- C.Code pneumonia from the report
- D.Code pneumonia as suspected
Answer: B. Inpatient diagnoses are coded from provider documentation, so a finding seen only in a radiology report is not coded on its own. A query lets the provider confirm or rule out its clinical significance.
9. Which data item may be coded from a dietitian's note, as long as the provider documents the related condition?
- A.Sepsis severity
- B.Body mass index
- C.Obesity diagnosis
- D.Type of diabetes
Answer: B. ICD-10-CM guidelines let BMI be taken from other clinicians' notes, but the associated diagnosis, such as obesity, must come from the patient's provider. Diagnoses themselves are not coded from a dietitian's note.
10. A review that checks whether every required report is present and signed is:
- A.Clinical coding audit
- B.Utilization review
- C.Qualitative analysis
- D.Quantitative analysis
Answer: D. Quantitative analysis checks completeness: required reports, signatures and dates. Qualitative analysis looks at whether the content is consistent and clinically sound.
Practice all 28 health records & data content questions, and the rest of the 200-question bank, in the free CCA training sets. Questions you miss come back until you have mastered them.
Start practicingFree to start. No account needed.