CCS CERTIFIED CLINICAL SUPERVISOR REAL
LATEST EXAM 2024-2025 WITH 100 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH
RATIONALES PLUS A COMPLETE EXAM
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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.discharge summary.pathology report.recovery room record. - ANSWER-pathology report.
Although a gross description of tissue removed may be mentioned on the operative note or discharge summary, only the pathology report will contain a microscopic description.
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.physicians' index.number control index.patient index. - ANSWER-disease index.
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The major sources of case findings for cancer registry programs are the pathology department, the disease index, and the logs of patients treated in radiology and other outpatient departments. The number index identifies new health record numbers and the patients to whom they were assigned. The physicians' index identifies all patients treated by each doctor. The patient index links each patient treated in a facility with the health number under which the clinical information can be located.
Joint Commission does not approve auto authentication of entries in a health record. The primary objection to this practice is that
it is too easy to delegate use of computer passwords.electronic signatures are not acceptable in every state.evidence cannot be provided that the physician actually reviewed and approved each report.tampering too often occurs with this method of authentication. - ANSWER- evidence cannot be provided that the physician actually reviewed and approved each report
Auto authentication is a policy adopted by some facilities that allow physicians to state in advance that transcribed reports should automatically be considered approved and signed (or authenticated) when the physician fails to make corrections within a preestablished time frame (e.g., "Consider it signed if I do not make changes within 7 days."). Another version of this practice is when physicians authorize the HIM department to send weekly lists of unsigned documents. The physician then signs the list in lieu of signing each individual report. Neither practice ensures that the physician has reviewed and approved each report individually.
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 2 / 4
the HIPAA Privacy Rule.Conditions of Coverage rules.meaningful use requirements.Joint Commission standards. - ANSWER-meaningful use requirements
Certified EHRs must have the functionality to allow the creation of an electronic copy of the patient's health record.
For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the
interdisciplinary patient care plan.discharge summary.transfer record.For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the
- ANSWER- interdisciplinary patient care plan.
problem list.discharge summary.transfer record.
Discharge summary documentation must include
correct codes for significant procedures.a note from social services or discharge planning.significant findings during hospitalization. 3 / 4
a detailed history of the patient. - ANSWER-significant findings during hospitalization.
Some reference to the patient's history may be found in the discharge summary but not a detailed history. The attending physician rather than a social worker records the discharge summary. Procedure codes are usually recorded on a different form in the record.
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.prohibited use of any abbreviations.use of abbreviations in the final diagnosis.flagrant use of specialty-specific abbreviations. - ANSWER-use of prohibited or "dangerous" abbreviations.
As part of its National Patient Safety Goals initiative, the Joint Commission required hospitals to prohibit abbreviations that have caused confusion or problems in their handwritten form, such as "U" for unit, which can be mistaken for "O".Spelling out the word "unit" is preferred.
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?
Review the medical records and/or imaging studies.Follow the daily surgical patient listing for the surgery suite if the patient has been sedated.
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