Deck 15: Medical Documents

Question 1

Voice recognition software, also known as speech recognition, automatic speech recognition, or language recognition software, does what?

A)Converts voice to text
B)Converts text to voice  
C)Recognizes hard-to-understand voices
D)None of the above

Answer 1

Converts voice to text

Question 2

Which turnaround time has the longest time frame to be completed?

A)ASAP
B)STAT  
C)Aged
D)Current

Answer 2

Aged

Question 3

Turnaround times for hospital reports fall into three categories.Which one is NOT a category?

A)ASAP
B)STAT  
C)Aged
D)Current

Answer 3

ASAP

Question 4

When transcribing radiology or imaging reports, what detail does NOT need to be included on the report?

A)Number of views taken
B)Date of dictation  
C)Normal findings
D)Radiologist's recommendations

Question 5

Which specialized report is also known as a necropsy report?

A)Radiology report
B)Pathology report  
C)Autopsy report
D)All of the above

Question 6

What issue(s) must be resolved in the physical transition from existing paper records to electronic health records?

A)The process by which the material is copyedited. 
B)How much of the paper chart to convert. 
C)How to make the majority of the clinical history available to the physician. 
D)Both b & c

Question 7

In order to become a CMT, you must take a voluntary examination from the:

A)AAMA
B)AMT  
C)AHDI
D)AMA

Question 8

Which of the following is NOT true about transcribing chart notes?

A)They are a concise description of the patient's encounter with the office. 
B)They are chronologically listed. 
C)They may chronicle the details of a surgical procedure performed in a hospital. 
D)They may include in-person visits to the office. 
E)They may include telephone inquiries.

Question 9

Which of the following is a common characteristic of an MT?

A)Detail-oriented
B)Independent  
C)Self-disciplined
D)All of the above

Question 10

Which of the following is NOT a common type of transcribed medical report?

A)History and physical report
B)Progress notes  
C)Pathology report
D)Consultation letter  
E)Diagnostic laboratory report

Question 11

What type of report chronicles the details of a surgical procedure?

A)Radiology report
B)Pathology report  
C)Autopsy report
D)Operative report

Question 12

When editing a transcription document, and you flag a certain area.What does this mean?

A)It is ready to be put on a legal document. 
B)It needs a physician's signature. 
C)You are unable to interpret the flagged area. 
D)There is an incorrect spelling.

Question 13

Today MTs may be more involved with all of the following EXCEPT?

A)Quality assurance (QA)
B)Risk management  
C)Editing documents
D)Dictating medical information

Question 14

In order for other providers, attorneys, or insurance companies to review medical reports, all of the following must be done EXCEPT what on all medical reports in the patient's medical record?

A)Must be scanned
B)Must be neat  
C)Must be complete
D)Must be accurate

Question 15

Important things to consider before outsourcing transcription include?

A)Be sure the office and the service use compatible hardware and software  
B)Be cost conscious  
C)Have a user-friendly method of tracking documents  
D)All of the above

Question 16

What is NOT considered an advantage of outsourcing medical transcription?

A)Frees administrative and support personnel to complete other tasks  
B)Frees floor space used to support line-item expense  
C)Outsourcing companies work 8 hours a day  
D)Saves on costly employee benefit packages

Question 17

Which of the following is the part of the history and physical examination report that contains information about the patient's symptoms, problems, or conditions which brought the patient to the office?

A)Family history
B)History of present illness  
C)Final diagnosis
D)Chief complaint

Question 18

Contracting with a service outside of the clinic or hospital with a company where a task can be accomplished at a lower cost with a faster turnaround time is known as what?

A)Cost contracting
B)Outsourcing  
C)Source efficiency
D)Insourcing

Question 19

The process of reviewing the transcribed document for accuracy and clarity is known as what?

A)Scanning
B)Editing  
C)Controlling
D)Cutting

Question 20

When one provider requests the services of another provider in the care and treatment of a patient, what type of report is generated?

A)Operative report
B)Consultation report  
C)Examination report
D)Referral report

Question 21

Match the common transcribed report to content found within the report.
surgical procedure and sponge count

A) radiology report
B) operative report
C) autopsy report
D) pathology report
E) H & P
F) consultation
G) discharge summary

Question 22

Match the common transcribed report to content found within the report.
temporary anatomic diagnosis

A) radiology report
B) operative report
C) autopsy report
D) pathology report
E) H & P
F) consultation
G) discharge summary

Question 23

Match the common transcribed report to content found within the report.
patient's history of hospital admissions

A) radiology report
B) operative report
C) autopsy report
D) pathology report
E) H & P
F) consultation
G) discharge summary

Question 24

Match the common transcribed report to content found within the report.
number and types of views taken

A) radiology report
B) operative report
C) autopsy report
D) pathology report
E) H & P
F) consultation
G) discharge summary

Question 25

Job opportunities should remain good for transcriptionists who are___?

A)experienced
B)new to the job market  
C)certified
D)employed by hospitals

Question 26

Match the common transcribed report to content found within the report.
elements of an H & P

A) radiology report
B) operative report
C) autopsy report
D) pathology report
E) H & P
F) consultation
G) discharge summary

Question 27

Match the common transcribed report to content found within the report.
chronological description of patient's illness

A) radiology report
B) operative report
C) autopsy report
D) pathology report
E) H & P
F) consultation
G) discharge summary

Question 28

Match the common transcribed report to content found within the report.
gross examination

A) radiology report
B) operative report
C) autopsy report
D) pathology report
E) H & P
F) consultation
G) discharge summary