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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 1.1.1)

1 / 5

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

(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 1.4.3)

3 / 5

Document formatting should begin flush with the left margin.

(Section 1.1.5)

4 / 5

A heading of ASSESSMENT is part of a SOAP note.

(Section 1.4.1)

5 / 5

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

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 1.1.7)

2 / 5

Procedure Notes and Operative Notes are the same.

(Section 1.1.6)

3 / 5

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

(Section 1.1.3)

4 / 5

A Referral Note must include the vital signs.

(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 1.1.16)

1 / 5

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

(Section 1.1.14)

2 / 5

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

(Section 1.5.4)

3 / 5

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

(Section 1.1.11)

4 / 5

C-CDA recommends a specific template for Pathology Reports.

(Section 1.1.8)

5 / 5

A Discharge Summary must include a PLAN OF TREATMENT section.

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 1.4.1)

2 / 5

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

(Section 1.2)

3 / 5

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

(Section 1.4.7)

4 / 5

Subheadings should be in all capital letters.

(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 CHIEF COMPLAINT section includes the clinician’s conclusion.

(Section 1.2)

3 / 5

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

(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 1.4.7)

1 / 5

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

(Section 1.3)

2 / 5

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

(Section 1.4.8)

3 / 5

Use double-line spacing between paragraphs.

(Section 1.4.10)

4 / 5

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

(Section 1.5.5)

5 / 5

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

Your score is

0%

Exit

Editing the Record

/5

Editing the Record - Quiz 1

(Section 2.1)

1 / 5

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

(Section 2.2.12)

2 / 5

You should refer derogatory remarks to risk management.

(Section 2.2.3)

3 / 5

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

(Section 2.2.1)

4 / 5

Verbatim transcription means it is error-free.

(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 82%

0%

/5

Editing the Record - Quiz 2

(Section 2.1.2)

1 / 5

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

(Section 2.2.12)

2 / 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)

3 / 5

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

(Section 2.3.6)

4 / 5

You must edit a run-on sentence.

(Section 2.2.5)

5 / 5

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

Your score is

The average score is 56%

0%

/5

Editing the Record - Quiz 3

(Section 2.2.1)

1 / 5

Verbatim transcription includes syntax errors.

(Section 2.2.2)

2 / 5

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

(Section 2.1.1)

3 / 5

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

(Section 2.2.5)

4 / 5

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

(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%

Punctuation

/5

Punctuation – Quiz 1

(section 3.4.1)

1 / 5

A comma should be used to separate two or more adjectives modifying the same noun.

(section 3.4.1)

(Section 3.4.5)

2 / 5

A comma should be used to separate groups of three numerals in five digits or more but omitted if the number includes a decimal

(Section 3.4.5)

(Section 3.1.3)

3 / 5

Abbreviations in treatment and drug dosing instructions should include a period.

(Section 3.1.3)

(Section 3.1.5)

4 / 5

Abbreviated units of measure should include a period.

(Section 3.1.5)

(Section 3.2)

5 / 5

When asking a question within a direct quote, the question mark should be inside the end quotation marks.

(Section 3.2)

Your score is

The average score is 63%

0%

/5

Punctuation – Quiz 2

(Section 3.6)

1 / 5

Use a colon followed by one space to separate the heading from a content set on the same line.

(Section 3.6)

(Section 3.4.12)

2 / 5

Commas are not used to separate values of a single panel or test.

(Section 3.4.12)

(Section 3.4.8)

3 / 5

Do not use a comma to separate the state and zip code.

(Section 3.4.8)

(Section 3.4.7)

4 / 5

Do not use a comma to separate a person’s name from a credential.

(Section 3.4.7)

(Section 3.4.6)

5 / 5

A comma should not be used to separate the day of the month from the year.

(Section 3.4.6)

Your score is

The average score is 73%

0%

/5

Punctuation – Quiz 3

(Section 3.6)

1 / 5

A colon should not be used in expressions of military time.

(Section 3.6)

(Section 3.8)

2 / 5

A hyphen should be used for all compound modifiers when they precede or modify a noun or pronoun.

(Section 3.8)

(Section 3.6)

3 / 5

A colon should not be used before a list or series of clauses.

(Section 3.6)

(Section 3.12.6)

4 / 5

Use a hyphen when fractions are expressed as words.

(Section 3.12.6)

(Section 3.7)

5 / 5

A semicolon should be used to separate two independent clauses.

(Section 3.7)

Your score is

The average score is 100%

0%

/5

Punctuation – Quiz 4

(Section 3.12.1)

1 / 5

A virgule may be used when expressing duality, taking the place of “or” or “and.”

(Section 3.12.1)

(Section 3.8.2)

2 / 5

Use a hyphen with all disease-entity modifiers that precede a noun.

(Section 3.8.2)

(Section 3.8.2)

3 / 5

Hyphens should be used to create compound modifiers formed with one-word modifiers and prefixes.

(Section 3.8.2)

(Section 3.8.9)

4 / 5

A hyphen should not be used with a prefix that precedes a proper noun.

(Section 3.8.9)

(Section 3.12.1)

5 / 5

You can use a virgule where two terms are of equal weight in the expression.

(Section 3.12.1)

Your score is

The average score is 80%

0%

/5

Punctuation – Quiz 5

(Section 3.13.2)

1 / 5

Punctuation marks should be inside the closing quotation marks in direct quotes.

(Section 3.13.2)

(Section 3.12.7)

2 / 5

A virgule should be used when expressing visual acuity with Arabic numerals.

(Section 3.12.7)

(Section 3.13.1)

3 / 5

Lower-case letters should be used to begin quotations if they represent an independent clause.

(Section 3.13.1)

(Section 3.13.3)

4 / 5

Double quotation marks should be used to represent feet and inches in dimensional expression.

(Section 3.13.3)

(Section 3.3)

5 / 5

When using an exclamation point as part of a direct quote, the exclamation point should be outside the quotation marks.

(Section 3.3)

Your score is

The average score is 100%

0%

/5

Punctuation – Quiz 6

(Section 3.12.6)

1 / 5

A virgule should be used to separate the numerator from the denominator in fractions.

(Section 3.12.6)

(Section 3.11)

2 / 5

Brackets should not be used within parenthetical insertions.

(Section 3.11)

(Section 3.9)

3 / 5

An em dash can be used in medical records.

(Section 3.9)

(Section 3.8.8)

4 / 5

Do not use a hyphen in place of the word to in a range expression.

(Section 3.8.8)

(Section 3.8.10)

5 / 5

A suspensive hyphen should be used after each incomplete modifier when there is a series of two or more hyphenated compounds that have a common last word.

(Section 3.8.10)

Your score is

The average score is 60%

0%

Capitalization

/5

Capitalization – Quiz 1

(Section 4.1)

1 / 5

The first word of every sentence should be capitalized.

(Section 4.1)

(Section 4.1.2)

2 / 5

Do not capitalize the first word after a colon if it is a proper noun or another word that is ordinarily capitalized.

(Section 4.1.2)

(Section 4.1.2)

3 / 5

Capitalize an independent question within a sentence.

(Section 4.1.2)

(Section 4.1.2)

4 / 5

Capitalize the first word of an independent clause after a colon.

(Section 4.1.2)

(Section 4.1.2)

5 / 5

Do not capitalize the first word after a colon when the material preceding the colon is a short introductory word, such as Note, Caution, or Wanted.

(Section 4.1.2)

Your score is

The average score is 67%

0%

/5

Capitalization – Quiz 2

(Section 4.1.6)

1 / 5

Capitalize the first word following the opening dash or parenthesis of a parenthetical question unless it is a proper noun or another word that is ordinarily capitalized.

(Section 4.1.6)

(Section 4.2.1)

2 / 5

Capitalize general occupational titles when they precede personal names.

(Section 4.2.1)

(Section 4.1.5)

3 / 5

Items in a list or an outline, even when items in the list represent single words, phrases, or clauses, should not be capitalized.

(Section 4.1.5)

(Section 4.2.1)

4 / 5

Capitalize all personal, executive, professional, civic, military, and religious titles that come immediately before the person’s name or that are used as part of their name or replacing their first name.

(Section 4.2.1)

(Section 4.1.4)

5 / 5

Capitalize the first word following the colon when used to set off a heading or subheading, especially in the case of the Review of Systems and Physical Exam.

(Section 4.1.4)

Your score is

The average score is 10%

0%

/5

Capitalization – Quiz 3

(Section 4.2.6)

1 / 5

Do not capitalize general references to legal terms, such as power of attorney, living will,, unless the full formal name of the low or document is referenced.

(Section 4.2.6)

(Section 4.2.4)

2 / 5

Capitalize credentials that are spelled out when they are generally referenced in a sentence unless they follow a personal name as a formal title.

(Section 4.2.4)

(Section 4.2.3)

3 / 5

Capitalize all words in literary and artistic titles except articles (the, an, a), short conjunctions, and short prepositions unless they occur as the first or last word of

(Section 4.2.3)

(Section 4.2.5)

4 / 5

Capitalize the word grade when referring to grade levels only when a number follows it but not when a number precedes it.

(Section 4.2.5)

(Section 4.2.2)

5 / 5

Family titles (e.g., mother, father, mom, dad) should not be capitalized when preceded by an article (explicit or implied) or a possessive pronoun.

(Section 4.2.2)

Your score is

The average score is 80%

0%

/5

Capitalization – Quiz 4

(Section 4.4.2)

1 / 5

Capitalize the abbreviated forms of company, corporation, incorporated, and limited when the business name incorporates those abbreviations in its formal name or title.

(Section 4.4.2)

(Section 4.4.2)

2 / 5

Capitalize the abbreviated forms of company, corporation, incorporated, and limited when the business name incorporates those abbreviations in its formal name or title.

(Section 4.4.2)

(Section 4.4)

3 / 5

Do not capitalize proper nouns and official names of a person, place, or thing.

(Section 4.4)

(Section 4.4.1)

4 / 5

Capitalize the O’ prefix in names that contain it but not the letter that follows the apostrophe.

(Section 4.4.1)

(Section 4.3)

5 / 5

Capitalize the trademark or unique name of a product and use lowercase for the descriptive terms.

(Section 4.3)

Your score is

The average score is 0%

0%

/5

Capitalization – Quiz 5

(Section 4.4.8)

1 / 5

Capitalize the names of races, languages, nationalities, ethnicities, tribes, political parties, religions, and religious denominations.

(Section 4.4.8)

(Section 4.4.7)

2 / 5

Capitalize the word city only when it is part of the name of the city, or in the nickname of that city.

(Section 4.4.7)

(Section 4.4.3)

3 / 5

Do not capitalize eponyms.

(Section 4.4.3)

(Section 4.4.4)

4 / 5

Do not capitalize common organizational terms, such as department, division, or committee, when they are expressed as general references.

(Section 4.4.4)

(Section 4.4.6)

5 / 5

Do not capitalize genus names used in plural and adjectival forms when used in the vernacular, or when they stand alone (without an epithet).

(Section 4.4.6)

Your score is

The average score is 0%

0%

/5

Capitalization – Quiz 6

(Section 4.4.8)

1 / 5

Capitalize the names of races, languages, nationalities, ethnicities, tribes, political parties, religions, and religious denominations.

(Section 4.4.8)

(Section 4.4.13)

2 / 5

Capitalize the days, months, holidays, and religious days.

(Section 4.4.13)

(Section 4.4.11)

3 / 5

Do not use initial capitals with computer commands, functions, or features.

(Section 4.4.11)

(Section 4.4.12)

4 / 5

Capitalize north, south, east, west, and words derived from these terms eastern, southeastern, etc.) when they identify a specific region or are part of a proper name.

(Section 4.4.12)

(Section 4.4.10)

5 / 5

Capitalize the names of special and historical events and the common nouns that accompany them.

(Section 4.4.10)

Your score is

The average score is 0%

0%

Plurals, Possessives, and Foreign Terms

/5

Plurals, Possessives, and Foreign Terms - Quiz 1

(Section 5.1.2)

1 / 5

There are words that retain the same form in the singular and plural.

(Section 5.1.2)

2 / 5

Nouns whose plurals are formed in unusual ways are considered regular forms.

(Section 5.1.1)

3 / 5

Add an “s” to most nouns in the singular to form the plural when preceded by a vowel.

(Section 5.1.1)

4 / 5

Add an “es” to nouns ending in a “y” when preceded by a consonant.

(Section 5.1.3)

5 / 5

Compound nouns are always expressed as separate words.

Your score is

The average score is 27%

0%

/5

Plurals, Possessives, and Foreign Terms - Quiz 2

(Section 5.1.4)

1 / 5

When you pluralize a proper noun, always retain the original spelling.

(Section 5.1.3)

2 / 5

For hyphenated compounds, pluralize the chief noun of the compound.

(Section 5.1.8)

3 / 5

Pluralize a single-digit number by adding only an “s".

(Section 5.1.9)

4 / 5

When referring to the common plural of genus, lowercase letters

(Section 5.1.7)

5 / 5

Do not form plurals for abbreviations by adding “s” to the singular abbreviation form.

Your score is

The average score is 60%

0%

/5

Plurals, Possessives, and Foreign Terms - Quiz 3

(Section 5.2.1)

1 / 5

Italicize foreign abbreviations, words, and phrases.

(Section 5.2.3)

2 / 5

When forming a plural for a Latin or Greek medical term, change “-en” to “-ina."

(Section 5.3.1)

3 / 5

Express possession of a singular noun that does not end in “s” by adding an apostrophe plus “s” to the noun.

(Section 5.2.2)

4 / 5

Spell out the English translation of Greek letters and capitalize.

(Section 5.3.4)

5 / 5

Express possession of compound nouns by adding an apostrophe at the end.

Your score is

The average score is 0%

0%

/5

Plurals, Possessives, and Foreign Terms - Quiz 4

(Section 5.2.3)

1 / 5

When forming a plural for Latin or Greek medical terms, change “-um” to “-a.”

(Section 5.2.3)

2 / 5

When forming a plural for Latin or Greek medical terms, change “-is” to “-es.”

(Section 5.1.7)

3 / 5

Do not form plurals for abbreviations by adding “s” to the singular abbreviation form.

(Section 5.1.7)

4 / 5

Do not form a plural for units of measure.

(Section 5.2.3)

5 / 5

Latin or Greek medical terms ending in “-us” are the same in singular and plural forms.

Your score is

The average score is 0%

0%

/5

Plurals, Possessives, and Foreign Terms - Quiz 5

(Section 5.3.4)

1 / 5

Express possession of compound nouns by adding an apostrophe at the end.

(Section 5.3.5)

2 / 5

Select the possessive form for personal pronouns.

(Section 5.3.5)

3 / 5

Avoid using contractions in clinical records for personal possessive pronouns.

(Section 5.3.2)

4 / 5

Express possession for nouns that end in “s” or “es” by adding an apostrophe before the “s.”

(Section 5.3.6)

5 / 5

Express possession of singular abbreviations by adding an “s” to the end of the abbreviation.

Your score is

The average score is 0%

0%

/5

Plurals, Possessives, and Foreign Terms - Quiz 6

(Section 5.2.2)

1 / 5

Spell out the English translation of Greek letters and capitalize.

(Section 5.1.7)

2 / 5

Form a plural of uppercase abbreviations by adding lowercase “s” to the abbreviation.

(Section 5.3.10)

3 / 5

Express possession of inanimate objects by using an apostrophe after “s.”

(Section 5.3.8)

4 / 5

To express joint possession by two or more individuals by adding the apostrophe plus “s” to both individuals.

(Section 5.3.8)

5 / 5

When two or more individuals are used to show separate possession, express them separately.

Your score is

The average score is 0%

0%