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Test Your Knowledge: Book of Style & Standards for Clinical Documentation, 4th Edition

Test your healthcare documentation skills with engaging quizzes based on the Book of Style & Standards for Clinical Documentation, 4th Edition. Perfect for medical transcriptionists, editors, healthcare documentation specialists, and CCD Auditors, these quick quizzes, separated into categories, will help reinforce learning, improve retention, and identify learning gaps so you can always perform at the top of your game.

🌟 What to Expect
✅ True/False questions
✅ Common style and formatting questions
✅ A fun, quick way to test or refresh your skills

Sharpen your skills, challenge yourself, and become a pro at applying industry standards with ease. Ready to test your expertise? Click on a quiz link to begin.

Document Types, Formats, and TATs

/5

Document Types, Formats, and TATs - Quiz 1

(Section 1.5.1)

1 / 5

According to the Joint Commission, the timeframe for completing a History and Physical report for admission is 48 hours.

(Section 1.1.1)

2 / 5

The PAST MEDICAL HISTORY section records the patient’s past complaints, problems, and diagnoses.

(Section 1.4.3)

3 / 5

Document formatting should begin flush with the left margin.

(Section 1.4.1)

4 / 5

Drug allergies recorded in the ALLERGIES AND INTOLERANCES section should be bold and all capital letters.

(Section 1.1.5)

5 / 5

A heading of ASSESSMENT is part of a SOAP note.

Your score is

0%

Exit

/5

Document Types, Formats, and TATs - Quiz 2

(Section 1.1.6)

1 / 5

There are reference standards for the order of headings in an Operative Note.

(Section 1.1.7)

2 / 5

Procedure Notes and Operative Notes are the same.

(Section 1.1.3)

3 / 5

A Referral Note must include the vital signs.

(Section 1.1.1)

4 / 5

History and Physical reports must be completed within twenty-four hours of hospital admission.

(Section 1.5.3)

5 / 5

The established regulation on a TAT for a Consultation Note is twelve hours.

Your score is

0%

Exit

/5

Document Types, Formats, and TATs - Quiz 3

(Section 1.5.4)

1 / 5

A Transfer Summary may be used instead of a Discharge Summary.

(Section 1.1.8)

2 / 5

A Discharge Summary must include a PLAN OF TREATMENT section.

(Section 1.1.11)

3 / 5

C-CDA recommends a specific template for Pathology Reports.

(Section 1.1.16)

4 / 5

In a Diagnostic Imaging Report, the only required heading is CONCLUSIONS.

(Section 1.1.14)

5 / 5

An electronic health record must be able to generate and exchange a Continuity of Care Document.

Your score is

0%

Exit

/5

Document Types, Formats, and TATs - Quiz 4

(Section 1.2)

1 / 5

A PREOPERATIVE DIAGNOSIS section includes the surgeon’s opinion on a diagnosis that will be confirmed by a procedure.

(Section 1.2)

2 / 5

A VITAL SIGNS section may include the patient’s height and weight.

(Section 1.4.7)

3 / 5

Subheadings should be in all capital letters.

(Section 1.2)

4 / 5

A DISCHARGE DIAGNOSIS section will include the problems and diagnoses that occurred during the hospitalization.

(Section 1.4.1)

5 / 5

A serif font is preferred for medical documentation for readability reasons.

Your score is

0%

Exit

/5

Document Types, Formats, and TATs - Quiz 5

(Section 1.4.8)

1 / 5

Use a double space after a period between sentences.

(Section 1.4.3)

2 / 5

All text should be typed flush to the left margin.

(Section 1.2)

3 / 5

The patient’s marital status is included in a GENERAL STATUS section.

(Section 1.2)

4 / 5

The CHIEF COMPLAINT section includes the clinician’s conclusion.

(Section 1.5.1)

5 / 5

History and physical exams should be performed within twenty-four hours of inpatient admission.

Your score is

0%

Exit

/5

Document Types, Formats, and TATs - Quiz 6

(Section 1.5.5)

1 / 5

The recommended TAT for a Progress Note is two to four hours.

(Section 1.4.7)

2 / 5

You may use the word “same” in a discharge diagnosis if the diagnosis is the same as the admission diagnosis.

(Section 1.3)

3 / 5

It is common to find the subheadings Head, Eyes, and Ears on a Review of Systems Report.

(Section 1.4.10)

4 / 5

Military time should only be used for the date- and time-stamps.

(Section 1.4.8)

5 / 5

Use double-line spacing between paragraphs.

Your score is

0%

Exit

Editing the Record

/5

Editing the Record - Quiz 1

(Section 2.2.3)

1 / 5

You should not edit syntax to maintain the dictator’s style.

(Section 2.1)

2 / 5

Flagging a document that needs to be reviewed by risk management is acceptable.

(Section 2.2.1)

3 / 5

Verbatim transcription means it is error-free.

(Section 2.2.12)

4 / 5

You should refer derogatory remarks to risk management.

(Section 2.2.2)

5 / 5

You may edit a medical record to correct translation errors made by speech recognition.

Your score is

The average score is 83%

0%

/5

Editing the Record - Quiz 2

(Section 2.2.7)

1 / 5

You should always correct dictated punctuation errors that do not affect meaning or readability.

(Section 2.3.6)

2 / 5

You must edit a run-on sentence.

(Section 2.2.5)

3 / 5

You should edit pronouns in the record to align with the patient’s gender.

(Section 2.1.2)

4 / 5

When a portion of dictation is missing, you should leave a blank and flag.

(Section 2.2.12)

5 / 5

Derogatory remarks about a patient’s family member should be left as dictated and flagged to Risk Management for review.

Your score is

The average score is 53%

0%

/5

Editing the Record - Quiz 3

(Section 2.2.2)

1 / 5

Speech recognition editing includes incorrect words and numbers that must be corrected.

(Section 2.1.1)

2 / 5

Flagging procedures should include a comment explaining the reason for clarification of a discrepancy.

(Section 2.1.3)

3 / 5

Audio indexing is used to help the editor know where they are in a record.

(Section 2.2.1)

4 / 5

Verbatim transcription includes syntax errors.

(Section 2.2.5)

5 / 5

Use the assigned gender at birth if a transgender patient’s identify preference is unknown.

Your score is

The average score is 63%

0%