Deck 4: Communications: Medical Records and Documentation

Question 1

____________ is defined as the act of transmitting information-an exchange of information between individuals using a common system of sings, symbols, or behavior.

A) Miscommunication
B) Speaking
C) Dialogue
D) Communication

Answer 1

D

Question 2

What type of communication emphasizes empathy?

A) Verbal
B) Therapeutic
C) Nonverbal
D) Documentation

Answer 2

B

Question 3

What is the first part of the communication cycle?

A) Receiver
B) Feedback
C) Message and channel
D) Sender

Answer 3

D

Question 4

What method of listening happens when the receiver rewords the original message to verify the message from the sender?

A) Active
B) Inactive
C) Nonverbal
D) Feedback

Question 5

Which of the following is one of the five C's of communication?

A) Complete
B) Concise
C) Cohesive
D) All of the above

Question 6

What accounts for 70% of a message's impact?

A) Verbal communication
B) Feedback
C) Active Listening
D) Non-verbal communication

Question 7

What is the study of body language called?

A) Calisthenics
B) Kinesics
C) Psychology
D) Hierarchy of needs

Question 8

Abraham Maslow is best known for the creation of what?

A) Hierarchy of needs
B) Culture diagram
C) Human psychology
D) Hierarchy of wants

Question 9

Important characteristics of patient chart documentation include which of the following?

A) Legible handwriting
B) Chronological order
C) Accurately and carefully recorded
D) All of the above

Question 10

The chief complaint, present illness, medical history, family history, social history, and review of systems (ROS) are all key parts of which of the following?

A) Patient charts
B) Patient surveys
C) Hierarchy of needs
D) Nonverbal communication

Question 11

What does the "S" in the acronym SOAP(ER) stand for?

A) Social history
B) Subjective data
C) Sensitivities
D) Soap

Question 12

What method of record documentation is similar to the SOAP method, but more detailed in nature?

A) CHEDDAR
B) HIPAA
C) AMA
D) NHCA

Question 13

What are EHRs?

A) Electronic Health Rates
B) Electronic Health Reports
C) Electronic Health Records
D) Electronic Health Repertoires

Question 14

HIPAA established which of the following standards for medical records?

A) Providing security of all electronic health information
B) Establishing standards for all electronic health transmission claims
C) Controlling and maintaining the privacy and security of private health information
D) All of the above

Question 15

How important is effective and efficient communication in the medical profession?

A) Somewhat important
B) Not important at all
C) Important
D) Extremely important

Question 16

What is the amount of personal space most often observed by individuals in social situations?

A) 1-2 feet
B) 3-5 feet
C) 4-12 feet
D) 5-8 feet

Question 17

A medical __________ types medical information spoken by the physician about the patient's examination or testing into a document that becomes a permanent part of the medical record.

A) Dictation
B) Transcriptionist
C) Assistant
D) Secretary

Question 18

When a patient cancels or refuses an appointment that is recommended, what should the medical assistant do?

A) Document this communication with the ordering physician
B) Ignore it
C) Insist that the patient keeps the appointment
D) Argue with the patient

Question 19

How should a medical assistant greet a patient upon arrival?

A) In a friendly and prompt manner
B) Not at all
C) With a frown
D) By wordlessly handing the patient paperwork

Question 20

How should a medical assistant handle private healthcare information?

A) Confidentially and within HIPAA compliance
B) By releasing patent records without authorization
C) By using another's password to access records
D) By leaving records unattended or out of sight

Question 21

What does the "H" stand for in the acronym CHEDDAR?

A) Hearing
B) Home life
C) History
D) Help wanted

Question 22

Who completes the review of systems or ROS section in a patient's chart?

A) Medical Assistant
B) Nurse
C) Transcriptionist
D) Physician

Question 23

What is the fifth and final level in Maslow's Hierarchy of Needs?

A) Security
B) Social
C) Esteem
D) Self-actualization