Bonewit-West Test Bank

Clinical Procedures for Medical Assistants 10th Edition Bonewit-West Test Bank

Chapter 01: The Medical Record

Bonewit-West: Clinical Procedures for Medical Assistants, 10th Edition

MULTIPLE CHOICE

• Which of the following is not a function of the medical record?
• To provide information for making decisions regarding the patient’s care
• To document the patient’s progress
• To serve as a legal document
• To share information between members of the patient’s family

ANS: D REF: p. 2| CAAHEP Competency (2015): VI.4

OBJ: 1

• What information is contained in the medical record?
• Health history report
• Results of the physical examination
• Laboratory reports
• Progress notes
• All of the above

ANS: E REF: pp. 2-3| CAAHEP Competency (2015): VI.4

OBJ: 2

• The purpose of the HIPAA Privacy Rule is to
• reduce exposure of patients to bloodborne pathogens.
• provide patients with betterNcUonRtSroIl NovGeTr tBh.e CusOe Mand disclosure of their health

information.

• prevent the patient’s records from being copied.
• encourage the patient to become more involved in preventive health care.

ANS: B REF: p. 4 | CAAHEP Competency (2015): IX.3

OBJ: 2

• All of the following are characteristics of the Notice of Privacy Practices except:
• Was developed by the American Medical Association
• Must explain how a patient’s health information will be used and protected by the

medical office

• Must be provided to each patient
• Must obtain a signed acknowledgment from the patient that he/she has received an

NPP ANS: A REF: p. 4| CAAHEP Competency (2015): IX.3

OBJ: 2

• Health information in any form that contains patient identifiable information is known as
• PHI.
• NPP.
• OSHA.
• HIPAA. 1 / 4

ANS: A REF: p. 4| CAAHEP Competency (2015): IX.3

OBJ: 2

• In which of the following situations does HIPAA not require written consent for the use or

disclosure of protected health information?

• Patient referral to a specialist
• Emergency care provided at a hospital
• Determination of eligibility for insurance benefits
• Training of health care students
• All of the above

ANS: E REF: p. 4| CAAHEP Competency (2015): IX.3

OBJ: 2

• Which of the following is not an example of a medical office clinical document?
• Patient registration record
• Physical examination report
• Medication record
• Health history report

ANS: A REF: pp. 2-3| CAAHEP Competency (2015): VI.4

OBJ: 2

• Which of the following is not a characteristic of a laboratory report?
• It relays results of laboratory tests to the provider
• It consists of a report of the analysis or examination of body specimens
• It assists in diagnosing and treating disease
• It is a request for laboratoryNtUesRtsStIo NbeGpTeBrf.orCmOeMd by an outside laboratory

ANS: D REF: pp. 2-3| CAAHEP Competency (2015): VI.4

OBJ: 2

• Which of the following is an example of a diagnostic procedure report?
• Electrocardiogram report
• Physical therapy report
• Urinalysis report
• Pathology report

ANS: A REF: pp. 2-3| CAAHEP Competency (2015): VI.4

OBJ: 2

• What is the name of the type of report that documents the assessments and treatments

designed to restore a patient’s ability to function?

• Consultation report
• Diagnostic procedure report
• Pathology report
• Therapeutic service report

ANS: D REF: pp. 2-3| CAAHEP Competency (2015): VI.4

OBJ: 2

• Which of the following is not an example of a hospital report?
• Operative report 2 / 4

NURSINGTB.COM

• Cytology report
• Discharge summary report
• Emergency department report

ANS: B REF: pp. 2-3| CAAHEP Competency (2015): VI.4

OBJ: 2

• Which of the following is an example of a consent document?
• Patient registration record
• Notice of Privacy Practices form
• Release of medical information form
• Patient instruction sheet

ANS: C REF: pp. 2-3| CAAHEP Competency (2015): VI.4

OBJ: 2

• Which of the following can be performed by an electronic medical record software program?
• Creation of a medical record
• Storage of a medical record
• Editing of a medical record
• Retrieval of a medical record
• All of the above

ANS: E REF: p. 3| CAAHEP Competency (2015): V.8

OBJ: 3

• All of the following are advantages of an electronic medical record (EMR) except
• an EMR does not have to be filed.
• documents in an EMR can be quickly retrieved.
• more than one person can view an EMR at the same time.
• EMRs are exempt from the HIPAA regulations.

ANS: D REF: pp. 3, 6| CAAHEP Competency (2015): VI.12

OBJ: 5

• Which of the following are used to enter data into an electronic medical record?
• Free-text entry
• Drop-down menus
• Radio buttons
• All of the above

ANS: D REF: p. 11| CAAHEP Competency (2015): V.8

OBJ: 8

• How are paper documents entered into a patient’s electronic medical record?
• By scanning them into the computer
• By retyping them on the computer
• By photocopying them
• By transmitting them through a modem

ANS: A REF: p. 11| CAAHEP Competency (2015): VI.4

OBJ: 8 3 / 4

OBJ: 8

• What is the name of a program that converts typed text into text that can be manipulated by

the computer (once it has been scanned into the computer)?

• POMR
• OCR
• Word processing program
• Practice management program

ANS: B REF: p. 6| CAAHEP Competency (2015): VI.12

OBJ: 4

• All of the following assist in the collection of data for a health history except
• a quiet, comfortable room.
• showing interest in the patient.
• showing concern for the patient.
• calling the patient “honey.”

ANS: D REF: p. 6| CAAHEP Competency (2015): V.3.

OBJ: 8

• Which of the following can be used to enter a health history into an electronic medical record?
• The patient completes a paper form and the medical assistant scans it into the

computer.

• The medical assistant enters information into the computer while asking the patient

questions.

• The patient completes a health history questionnaire on a computer.
• All of the above

ANS: D REF: p. 6| N C U A R A S H I EP NG Co T m B p .et C en O cy M

(2015): IX.12

• What is a health history?
• A legal document required to perform certain procedures on a patient
• Documentation of the results of the physical examination
• A collection of subjective data about the patient
• A narrative description and interpretation of a diagnostic procedure

ANS: C REF: p. 6| CAAHEP Competency (2015): V.10

OBJ: 6

• The health history is taken
• after the provider performs the physical examination.
• after laboratory test results are reviewed.
• before the provider performs the physical examination.
• after the provider makes a diagnosis of the patient’s condition.

ANS: C REF: p. 6| CAAHEP Competency (2015): VI.4

OBJ: 6

• What is the chief complaint?
• The probable outcome of the patient’s condition
• The symptom causing the patient the most trouble
• A detailed description of the patient’s illness using medical terms
• / 4