Deck 1: The Medical Record

Question 1

The purpose of HIPAA is to

A)reduce exposure of patients to bloodborne pathogens.
B)provide patients with more control over the use and disclosure of their health information.
C)prevent the patient's records from being copied.
D)encourage the patient to become more involved in preventive health care.

Answer 1

provide patients with more control over the use and disclosure of their health information.

Question 2

Which of the following provides subjective data about a patient to assist the physician in arriving at a diagnosis?

A)Laboratory tests
B)Physical examination
C)Health history
D)Diagnostic tests

Answer 2

Health history

Question 3

Which of the following is not included on a medication record for medication administered at the office?

A)Name of the medication
B)Route of administration
C)Dosage administered
D)Number of refills

Answer 3

Number of refills

Question 4

What term is used to describe a patient who has been admitted to the hospital for at least one overnight stay?

A)Outpatient
B)Ambulatory patient
C)Guest
D)Inpatient

Question 5

Which of the following reports consists of a macroscopic and microscopic description of tissue removed during surgery?

A)Laboratory report
B)Pathology report
C)Diagnostic imaging report
D)Operative report

Question 6

Which of the following reports consists of an account of the significant events of a patient's hospitalization?

A)Emergency department report
B)Pathology report
C)History and physical report
D)Discharge summary report

Question 7

A report of the analysis of body specimens is known as a _____ report.

A)therapeutic
B)diagnostic
C)laboratory
D)progress

Question 8

All of the following are included in the patient registration record except

A)date of birth.
B)allergies.
C)employer.
D)patient's insurance company.

Question 9

Which of the following services may be provided through home health care?

A)IV therapy
B)Respiratory care
C)Rehabilitation
D)Maternal-child care
E)All of the above

Question 10

Conclusions drawn from an interpretation of data are known as

A)medical impressions.
B)prognosis.
C)symptoms.
D)charting.

Question 11

A consent to treatment form is required for

A)tuberculin skin testing.
B)sebaceous cyst removal.
C)ear irrigation.
D)blood pressure measurement.

Question 12

Which of the following is not a function of the medical record?

A)To provide information for making decisions regarding the patient's care
B)To document the patient's progress
C)To serve as a legal document
D)To share information between members of the patient's family

Question 13

A copy of the patient's emergency department report is sent to the

A)patient's insurance company.
B)patient.
C)patient's family physician.
D)laboratory.

Question 14

A narrative report of an opinion about a patient's condition by a practitioner other than the attending physician is known as a _____ report.

A)correspondence
B)discharge summary
C)consultation
D)health history

Question 15

All of the following are included in an operative report except

A)the name of the surgical procedure.
B)description of the procedure used during surgery.
C)prognosis.
D)postoperative diagnosis.

Question 16

Which of the following helps a patient with a disability learn new skills to perform the activities of daily living?

A)Speech therapy
B)Occupational therapy
C)Physical therapy
D)Dietitian

Question 17

All of the following are examples of diagnostic reports except _____ report.

A)urinalysis
B)spirometry
C)colonoscopy
D)radiology

Question 18

All of the following are examples of physical therapy except

A)electrical stimulation.
B)hydrotherapy.
C)therapeutic exercise.
D)breathing treatments.

Question 19

The patient registration record consists of

A)demographic and billing information.
B)medication instructions given to the patient.
C)the results of the physical examination.
D)a list of problems associated with the patient's illness.
E)all of the above.

Question 20

What information is contained in the medical record?

A)Health history
B)Results of the physical examination
C)Laboratory reports
D)Progress notes
E)All of the above

Question 21

In a source-oriented record,a radiology report is filed under which of the following chart dividers?

A)History and Physical
B)Progress Notes
C)Lab/X-ray
D)Hospital

Question 22

All of the following are advantages of an electronic medical record (EMR)except

A)an EMR does not have to be filed.
B)documents in an EMR can be quickly retrieved.
C)more than one person can view an EMR at the same time.
D)EMRs are exempt from the HIPAA regulations.

Question 23

All of the following are included in the database section of a POR except

A)health history report.
B)physical examination report.
C)baseline laboratory test results.
D)plan of treatment.

Question 24

Which of the following must be included in informed consent?

A)An explanation of risks involved with the procedure
B)Any alternative treatments or procedures available
C)The prognosis
D)The purpose of the recommended procedure
E)All of the above

Question 25

The physician's interpretation of the patient's condition is recorded in POR progress notes under

A)subjective data.
B)objective data.
C)assessment.
D)plan.

Question 26

Which of the following can be performed by an electronic medical record software program?

A)Creation of a medical record
B)Storage of a medical record
C)Editing of a medical record
D)Retrieval of a medical record
E)All of the above

Question 27

What is the chief complaint?

A)The probable outcome of the patient's condition
B)The symptom causing the patient the most trouble
C)A detailed description of the patient's illness using medical terms
D)A tentative diagnosis of the patient's condition

Question 28

Which of the following questions should be used to elicit the chief complaint from a patient?

A)Where does it hurt?
B)Are you sick?
C)How long have you been ill?
D)What seems to be the problem?
E)All of the above are correct.

Question 29

How are paper documents entered into a patient's electronic medical record?

A)By scanning them into the computer
B)By retyping them on the computer
C)By photocopying them
D)By transmitting them through a modem

Question 30

The purpose of the tab on a file folder is to

A)hold documents in place in the folder.
B)identify the contents of the folder.
C)prevent the folder from being misfiled.
D)keep the folder closed when not in use.

Question 31

The acronym for the format used to organize POR progress notes is

A)SOAP.
B)TGIF.
C)OSHA.
D)PPR.

Question 32

All of the following assist in the collection of data for a health history except

A)a quiet, comfortable room.
B)showing interest in the patient.
C)showing concern for the patient.
D)calling the patient "honey."

Question 33

The health history is taken

A)after the physician performs the physical examination.
B)after laboratory test results are reviewed.
C)before the physician performs the physical examination.
D)after the physician makes a diagnosis of the patient's condition.

Question 34

All of the following are included on a release of medical information form except

A)the specific information to be released.
B)the need for the information.
C)the patient's signature.
D)the expiration date of the release form.
E)medications being taken by the patient.

Question 35

When a medical assistant witnesses a patient's signature,it means that he or she verified

A)the patient's identity and watched the patient sign the form.
B)that the information on the form is correct.
C)that the patient is aware of the risks involved with the procedure to be performed.
D)that the physician discussed informed consent with the patient.

Question 36

Data obtained from the patient are recorded in POR progress notes under

A)subjective data.
B)objective data.
C)assessment.
D)plan.

Question 37

Which of the following situations requires the completion of a release of medical information form?

A)When a patient transfers records to a new physician
B)To bill the patient's insurance company
C)To send the patient's records to a consulting physician
D)To determine the patient's eligibility for insurance benefits

Question 38

Which of the following are used to enter data into an electronic medical record?

A)Free-text entry
B)Drop-down lists
C)Check boxes
D)All of the above

Question 39

Which of the following can be used to enter a health history into an electronic medical record?

A)The patient completes a paper form and the medical assistant scans it into the computer.
B)The medical assistant enters information while asking the patient questions.
C)The patient completes a health history on a computer.
D)All of the above are correct.

Question 40

With reverse chronological order,the most recent document is

A)filed alphabetically.
B)filed by subject title.
C)placed in front of the other documents.
D)placed in back of the other documents.

Question 41

Which of the following is a correct example for recording the chief complaint?

A)"Complains of pain in the left shoulder."
B)"The patient does not feel well today."
C)"Burning in the chest and coughing for the past 2 days."
D)"Otitis media that began following a cold."

Question 42

What is the ROS?

A)A history of the patient's previous diseases, injuries, and operations
B)The symptom causing the patient the most trouble
C)A systematic review of each body system
D)A review of the hereditary diseases and health of blood relatives

Question 43

What is a symptom?

A)Conclusions drawn from an interpretation of data
B)Any change in the body or its functioning that indicates disease
C)The probable outcome of a disease
D)The scientific method of identifying a patient's condition

Question 44

The social history is important because which of the following may affect the patient's condition?

A)Lifestyle
B)Familial diseases
C)Past injuries
D)Medications being taken by the patient

Question 45

All of the following are included in the social history except

A)dietary history.
B)health habits.
C)occupation.
D)chronic illnesses.

Question 46

A procedure should be charted immediately after being performed to

A)avoid charting the procedure out of sequence.
B)avoid performing the wrong procedure on a patient.
C)avoid forgetting certain aspects of the procedure.
D)prevent another staff member from charting the procedure.

Question 47

What is an objective symptom?

A)A symptom that can be observed by another person
B)A symptom that precedes a disease
C)A symptom that is felt by the patient and cannot be observed by another
D)The symptom causing the patient the most trouble

Question 48

All of the following are included in the medical history except

A)accidents and injuries.
B)immunizations.
C)operations.
D)medications.
E)occupation.

Question 49

What is the medical history?

A)The patient's previous diseases, injuries, and operations
B)The symptom causing the patient the most trouble
C)Information about the patient's lifestyle
D)The hereditary diseases and health of blood relatives

Question 50

Laboratory tests ordered on a patient at an outside laboratory should be charted to provide documentation in case which of the following occurs?

A)The patient does not undergo the test.
B)The test results are abnormal.
C)The patient's condition gets worse.
D)The test results are negative.

Question 51

The purpose of progress notes is to

A)provide a review of each body system.
B)update the medical record with new patient information.
C)prevent the patient's condition from getting worse.
D)ensure that the patient returns for follow-up care.

Question 52

Which of the following is an example of a subjective symptom?

A)Rash
B)Pain
C)Dyspnea
D)Bleeding

Question 53

Why should a recording in the medical record never be erased or obliterated?

A)It makes it harder to read the chart.
B)The patient may not receive the proper care.
C)Credibility is reduced if the physician is involved in litigation.
D)It indicates the procedure was performed incorrectly.

Question 54

Which of the following is an example of a familial disease?

A)Tuberculosis
B)Pneumonia
C)Diabetes mellitus
D)Emphysema

Question 55

An expansion of the chief complaint is known as the

A)review of systems.
B)present illness.
C)progress report.
D)provisional diagnosis.

Question 56

What term is used to describe the process of making written entries about a patient in the medical record?

A)Charting
B)Registration
C)Scribbling
D)Documentation

Question 57

A review of the health status of blood relatives is known as

A)family history.
B)review of systems.
C)genetic review.
D)chronological history.

Question 58

Black ink should be used when recording in the patient's chart to

A)provide a permanent record.
B)ensure legible handwriting.
C)avoid spelling errors.
D)reduce charting errors.

Question 59

Which of the following is the correct way to sign a charting entry?

A)D.B., CMA (AAMA)
B)Dawn C.Bennett, CMA (AAMA)
C)D.Bennett, CMA (AAMA)
D)Bennett, CMA (AAMA)

Question 60

All of the following must be done when charting except

A)begin each new entry on a separate line.
B)include the patient's name at the beginning of each entry.
C)begin each phrase with a capital letter.
D)include the date and time with each entry.

Question 61

What term is used to describe excessive perspiration?

A)Dehydration
B)Diaphoresis
C)Edema
D)Hyperemesis

Question 62

Flushed skin usually indicates the patient

A)is experiencing pain.
B)has an elevated temperature.
C)has chills.
D)has a rash.

Question 63

What term is used to describe dizziness?

A)Epistaxis
B)Vertigo
C)Urticaria
D)Pruritus

Question 64

A decrease in the amount of water in the body is known as

A)edema.
B)acidosis.
C)epistaxis.
D)dehydration.

Question 65

Why is it important to document any instructions provided to the patient?

A)To ensure that the patient understands the instructions provided
B)To protect the physician legally if the patient is harmed by not following the instructions
C)To ensure that the patient follows the instructions
D)To provide a record for the insurance company

Question 66

A yellow color of the skin that is first observed in the whites of the eyes is called

A)cyanosis.
B)hepatitis.
C)pallor.
D)jaundice.