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Clinical Procedures for Medical Assistants 9th Edition by Bonewit West Test Bank

Chapter 1: The Medical Record

Test Bank

MULTIPLE CHOICE

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

ANS: E TOP: CAAHEP Cognitive Competency Met: V. 6

• 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 TOP: CAAHEP Cognitive Competency Met: V. 6

• The purpose of HIPAA is to
• reduce exposure of patients to bloodborne pathogens.
• provide patients with more control over the use and 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 TOP: CAAHEP Cognitive Competency Met: IX. 3

• The patient registration record consists of
• demographic and billing information.
• medication instructions given to the patient.
• the results of the physical examination.
• a list of problems associated with the patient’s illness.
• all of the above.

ANS: A TOP: CAAHEP Cognitive Competency Met: V. 6

• All of the following are included in the patient registration record except
• date of birth.
• allergies.
• employer.
• patient’s insurance company.

ANS: B TOP: CAAHEP Cognitive Competency Met: V. 6

• Which of the following provides subjective data about a patient to assist the physician in

arriving at a diagnosis?

• Laboratory tests 1 / 4

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• Physical examination
• Health history
• Diagnostic tests

ANS: C TOP: CAAHEP Cognitive Competency Met: IV. 6

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

the office?

• Name of the medication
• Route of administration
• Dosage administered
• Number of refills

ANS: D TOP: CAAHEP Cognitive Competency Met: V. 6

• A narrative report of an opinion about a patient’s condition by a practitioner other than the

attending physician is known as a report.

• correspondence
• discharge summary
• consultation
• health history

ANS: C TOP: CAAHEP Cognitive Competency Met: V. 12

• Which of the following services may be provided through home health care?
• IV therapy
• Respiratory care
• Rehabilitation
• Maternal-child care
• All of the above

ANS: E TOP: CAAHEP Cognitive Competency Met: I. 9

• A report of the analysis of body specimens is known as a report.
• therapeutic
• diagnostic
• laboratory
• progress

ANS: C TOP: CAAHEP Cognitive Competency Met: V. 12

• All of the following are examples of diagnostic reports except report.
• urinalysis
• spirometry
• colonoscopy
• radiology

ANS: A TOP: CAAHEP Cognitive Competency Met: V. 12

• All of the following are examples of physical therapy except
• electrical stimulation.
• hydrotherapy.
• therapeutic exercise. 2 / 4

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• breathing treatments.

ANS: D

CAAHEP Cognitive Competency Met: I. 9

• Which of the following helps a patient with a disability learn new skills to perform the

activities of daily living?

• Speech therapy
• Occupational therapy
• Physical therapy
• Dietitian

ANS: B TOP: CAAHEP Cognitive Competency Met: IV. 11

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

overnight stay?

• Outpatient
• Ambulatory patient
• Guest
• Inpatient

ANS: D TOP: CAAHEP Cognitive Competency Met: IV. 11

• Conclusions drawn from an interpretation of data are known as
• medical impressions.
• prognosis.
• symptoms.
• charting.

ANS: A TOP: CAAHEP Cognitive Competency Met: IV. 11

• All of the following are included in an operative report except
• the name of the surgical procedure.
• description of the procedure used during surgery.
• prognosis.
• postoperative diagnosis.

ANS: C TOP: CAAHEP Cognitive Competency Met: V. 12

• Which of the following reports consists of an account of the significant events of a patient’s

hospitalization?

• Emergency department report
• Pathology report
• History and physical report
• Discharge summary report

ANS: D TOP: CAAHEP Cognitive Competency Met: V. 12

• Which of the following reports consists of a macroscopic and microscopic description of

tissue removed during surgery?

• Laboratory report
• Pathology report
• Diagnostic imaging report 3 / 4

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• Operative report

ANS: B TOP: CAAHEP Cognitive Competency Met: V. 12

• A copy of the patient’s emergency department report is sent to the
• patient’s insurance company.
• patient.
• patient’s family physician.
• laboratory.

ANS: C TOP: CAAHEP Cognitive Competency Met: I. 9

• A consent to treatment form is required for
• tuberculin skin testing.
• sebaceous cyst removal.
• ear irrigation.
• blood pressure measurement.

ANS: B TOP: CAAHEP Cognitive Competency Met: V. 12

• Which of the following must be included in informed consent?
• An explanation of risks involved with the procedure
• Any alternative treatments or procedures available
• The prognosis
• The purpose of the recommended procedure
• All of the above

ANS: E TOP: CAAHEP Cognitive Competency Met: IX. 13

• When a medical assistant witnesses a patient’s signature, it means that he or she verified
• the patient’s identity and watched the patient sign the form.
• that the information on the form is correct.
• that the patient is aware of the risks involved with the procedure to be performed.
• that the physician discussed informed consent with the patient.

ANS: A TOP: CAAHEP Cognitive Competency Met: IX. 13

• Which of the following situations requires the completion of a release of medical information

form?

• When a patient transfers records to a new physician
• To bill the patient’s insurance company
• To send the patient’s records to a consulting physician
• To determine the patient’s eligibility for insurance benefits

ANS: A TOP: CAAHEP Cognitive Competency Met: IX. 13

• All of the following are included on a release of medical information form except
• the specific information to be released.
• the need for the information.
• the patient’s signature.
• the expiration date of the release form.
• medications being taken by the patient.
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