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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 1.4.1)

1 / 5

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

(Section 1.5.1)

2 / 5

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

(Section 1.1.5)

3 / 5

A heading of ASSESSMENT is part of a SOAP note.

(Section 1.1.1)

4 / 5

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

(Section 1.4.3)

5 / 5

Document formatting should begin flush with the left margin.

Your score is

0%

Exit

/5

Document Types, Formats, and TATs - Quiz 2

(Section 1.1.1)

1 / 5

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

(Section 1.1.3)

2 / 5

A Referral Note must include the vital signs.

(Section 1.1.7)

3 / 5

Procedure Notes and Operative Notes are the same.

(Section 1.5.3)

4 / 5

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

(Section 1.1.6)

5 / 5

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

Your score is

0%

Exit

/5

Document Types, Formats, and TATs - Quiz 3

(Section 1.1.8)

1 / 5

A Discharge Summary must include a PLAN OF TREATMENT section.

(Section 1.1.16)

2 / 5

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

(Section 1.1.11)

3 / 5

C-CDA recommends a specific template for Pathology Reports.

(Section 1.5.4)

4 / 5

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

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

(Section 1.2)

2 / 5

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

(Section 1.4.7)

3 / 5

Subheadings should be in all capital letters.

(Section 1.4.1)

4 / 5

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

(Section 1.2)

5 / 5

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

Your score is

0%

Exit

/5

Document Types, Formats, and TATs - Quiz 5

(Section 1.4.3)

1 / 5

All text should be typed flush to the left margin.

(Section 1.2)

2 / 5

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

(Section 1.2)

3 / 5

The CHIEF COMPLAINT section includes the clinician’s conclusion.

(Section 1.5.1)

4 / 5

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

(Section 1.4.8)

5 / 5

Use a double space after a period between sentences.

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 1.4.10)

2 / 5

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

(Section 1.3)

3 / 5

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

(Section 1.4.8)

4 / 5

Use double-line spacing between paragraphs.

(Section 1.4.7)

5 / 5

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

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 2.2.1)

2 / 5

Verbatim transcription means it is error-free.

(Section 2.2.2)

3 / 5

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

(Section 2.1)

4 / 5

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

(Section 2.2.12)

5 / 5

You should refer derogatory remarks to risk management.

Your score is

The average score is 83%

0%

/5

Editing the Record - Quiz 2

(Section 2.3.6)

1 / 5

You must edit a run-on sentence.

(Section 2.1.2)

2 / 5

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

(Section 2.2.5)

3 / 5

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

(Section 2.2.12)

4 / 5

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

(Section 2.2.7)

5 / 5

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

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 2.2.5)

3 / 5

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

(Section 2.2.1)

4 / 5

Verbatim transcription includes syntax errors.

(Section 2.1.3)

5 / 5

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

Your score is

The average score is 63%

0%