CCA Exam Domain 3 Latest
Which of the following elements is not a component of mos patient records
A. Patient identification
B Clinical history
C. Financial information
D. Test results - CORRECT ANSWER Financial information
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 - CORRECT ANSWER Operative report
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 - CORRECT ANSWER Pathology report
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 - CORRECT ANSWER Radiography report
The____ provided the impetus for standardizing health care records with minimum standards early
in the twentieth centry? - CORRECT ANSWER ACS
, 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 - CORRECT ANSWER Pathology report
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 - CORRECT ANSWER Admission order
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 - CORRECT ANSWER Newborn record
The following is documented in an acute care record: Atrial fibriliation 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 - CORRECT ANSWER ECG report
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