Question 1

When using the POMR method of record keeping,which of the following types of information appear on the same page?

Accepted Answer

A)  medication lists and preventive care lists 
B)  the chief complaint and list chronic problems 
C)  education information provided to the patient,and the review of systems 
D)  the patient profile and list of chronic problems 
A)  medication lists and preventive care lists 
B)  the chief complaint and list chronic problems 
C)  education information provided to the patient,and the review of systems 
D)  the patient profile and list of chronic problems

Question 2

What do the two Ds in CHEDDAR stand for?

Accepted Answer

A)  details and drugs 
B)  drug to drug 
C)  details and documentation 
D)  dosages and documentation 
A)  details and drugs 
B)  drug to drug 
C)  details and documentation 
D)  dosages and documentation

Question 3

Match each term with its definition.
-Method of charting that encourages a clinician to provide greater detail of the information obtained during the interview and examination

Accepted Answer

A) privacy officer 
B) imaging 
C) correction fluid 
D) tickler file 
E) physician's order
F)color-coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports 
A) privacy officer 
B) imaging 
C) correction fluid 
D) tickler file 
E) physician's order
F)color-coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 4

Match each example of information to the part of the medical record in which it would be found.
-Patient's immunization record from the previous provider

Accepted Answer

A) administrative data 
B) financial and insurance information 
C) correspondence 
D) referral 
E) past medical records
F)medications
G)progress notes
H)diagnostic imaging information
I)lab information 
A) administrative data 
B) financial and insurance information 
C) correspondence 
D) referral 
E) past medical records
F)medications
G)progress notes
H)diagnostic imaging information
I)lab information

Question 5

When you purge a file,you:

Accepted Answer

A)  update it 
B)  clean it out 
C)  correct information in it 
D)  make a copy of it 
A)  update it 
B)  clean it out 
C)  correct information in it 
D)  make a copy of it

Question 6

​Stage 1 of meaningful use focuses on data capture and sharing stage.Match the objectives to the description.Note: Answer may be used more than once.
-​Implement drug-drug and drug-allergy interaction checks

Accepted Answer

A) Stage 1-List of Eligible Professional Core Objectives 
B) Stage 1-Eligible Professional Menu Set Objectives 
A) Stage 1-List of Eligible Professional Core Objectives 
B) Stage 1-Eligible Professional Menu Set Objectives

Question 7

​Stage 1 of meaningful use focuses on data capture and sharing stage.Match the objectives to the description.Note: Answer may be used more than once.
-​Maintain active medication list

Accepted Answer

A) Stage 1-List of Eligible Professional Core Objectives 
B) Stage 1-Eligible Professional Menu Set Objectives 
A) Stage 1-List of Eligible Professional Core Objectives 
B) Stage 1-Eligible Professional Menu Set Objectives

Question 8

Match each example of information to the part of the medical record in which it would be found.
-Request-of-information letter from a patient's insurance company

Accepted Answer

A) administrative data 
B) financial and insurance information 
C) correspondence 
D) referral 
E) past medical records
F)medications
G)progress notes
H)diagnostic imaging information
I)lab information 
A) administrative data 
B) financial and insurance information 
C) correspondence 
D) referral 
E) past medical records
F)medications
G)progress notes
H)diagnostic imaging information
I)lab information

Question 9

Match each term with its definition.
-These typically bear a disclaimer that states the report has or has not been reviewed for accuracy

Accepted Answer

A) privacy officer 
B) imaging 
C) correction fluid 
D) tickler file 
E) physician's order
F)color-coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports 
A) privacy officer 
B) imaging 
C) correction fluid 
D) tickler file 
E) physician's order
F)color-coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 10

Match each term with its definition.
-Designated individual who keeps track of which individuals have access to protected health information within a facility

Accepted Answer

A) privacy officer 
B) imaging 
C) correction fluid 
D) tickler file 
E) physician's order
F)color-coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports 
A) privacy officer 
B) imaging 
C) correction fluid 
D) tickler file 
E) physician's order
F)color-coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 11

When filing records in a new file cabinet,it is recommended that you:

Accepted Answer

A)  space out files evenly in all drawers 
B)  place files in the middle drawers first 
C)  place files in the top drawer first 
D)  place files in the bottom drawers first 
A)  space out files evenly in all drawers 
B)  place files in the middle drawers first 
C)  place files in the top drawer first 
D)  place files in the bottom drawers first

Question 12

​Stage 1 of meaningful use focuses on data capture and sharing stage.Match the objectives to the description.Note: Answer may be used more than once.
-​Implement one clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance with that rule

Accepted Answer

A) Stage 1-List of Eligible Professional Core Objectives 
B) Stage 1-Eligible Professional Menu Set Objectives 
A) Stage 1-List of Eligible Professional Core Objectives 
B) Stage 1-Eligible Professional Menu Set Objectives

Question 13

​Each filing system has pros and cons.Match the filing system to the "pros" description provided.
-​Useful in community health environments

Accepted Answer

A) ​alphabetic 
B) ​numeric 
C) ​geographic 
D) ​subject 
E) ​chronologic 
A) ​alphabetic 
B) ​numeric 
C) ​geographic 
D) ​subject 
E) ​chronologic

Question 14

​Match the filing steps for medical records to the description.
-​Step Four: put papers in alphabetical order

Accepted Answer

A) ​inspecting 
B) indexing 
C) ​coding 
D) ​sorting 
E) ​storing 
A) ​inspecting 
B) indexing 
C) ​coding 
D) ​sorting 
E) ​storing

Question 15

Which of the following is not an advantage of EHRs?

Accepted Answer

A)  They facilitate coordination of care among providers. 
B)  They completely eliminate the necessity for paper records. 
C)  They can assign CPT and ICD codes at the time of the visit. 
D)  They make chart notes immediately available when a referral is needed. 
A)  They facilitate coordination of care among providers. 
B)  They completely eliminate the necessity for paper records. 
C)  They can assign CPT and ICD codes at the time of the visit. 
D)  They make chart notes immediately available when a referral is needed.

Question 16

​Each filing system has pros and cons.Match the filing system to the "pros" description provided.
-​Distributes files evenly over given spaces

Accepted Answer

A) ​alphabetic 
B) ​numeric 
C) ​geographic 
D) ​subject 
E) ​chronologic 
A) ​alphabetic 
B) ​numeric 
C) ​geographic 
D) ​subject 
E) ​chronologic

Question 17

Which of the following is an objective statement?

Accepted Answer

A)  You don't look well. 
B)  Mrs.Smith says her mouth feels dry. 
C)  I have a headache. 
D)  The patient's heart rate is elevated at 120 beats per minute. 
A)  You don't look well. 
B)  Mrs.Smith says her mouth feels dry. 
C)  I have a headache. 
D)  The patient's heart rate is elevated at 120 beats per minute.

Question 18

​Stage 1 of meaningful use focuses on data capture and sharing stage.Match the objectives to the description.Note: Answer may be used more than once.
-​The EP who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation

Accepted Answer

A) Stage 1-List of Eligible Professional Core Objectives 
B) Stage 1-Eligible Professional Menu Set Objectives 
A) Stage 1-List of Eligible Professional Core Objectives 
B) Stage 1-Eligible Professional Menu Set Objectives

Question 19

It is recommended that filing dividers or guides be constructed of _____ material.

Accepted Answer

A)  heavy,sturdy 
B)  light,flexible 
C)  transparent,flexible 
D)  sturdy,magnetic 
A)  heavy,sturdy 
B)  light,flexible 
C)  transparent,flexible 
D)  sturdy,magnetic

Question 20

​Which of the following would be a subjective statement?

Accepted Answer

A)  ​You don't look well. 
B)  ​Your blood pressure is 124/92. 
C)  ​Your blood sugar is 325 mg/dL. 
D)  ​The patient's temperature is 37.9C/100.2F. 
A)  ​You don't look well. 
B)  ​Your blood pressure is 124/92. 
C)  ​Your blood sugar is 325 mg/dL. 
D)  ​The patient's temperature is 37.9C/100.2F.

Exam 26: The Medical Record,documentation,and Filing

When using the POMR method of record keeping,which of the following types of information appear on the same page?

What do the two Ds in CHEDDAR stand for?

Match each term with its definition. -Method of charting that encourages a clinician to provide greater detail of the information obtained during the interview and examination

Match each example of information to the part of the medical record in which it would be found. -Patient's immunization record from the previous provider

When you purge a file,you:

​Stage 1 of meaningful use focuses on data capture and sharing stage.Match the objectives to the description.Note: Answer may be used more than once. -​Implement drug-drug and drug-allergy interaction checks

​Stage 1 of meaningful use focuses on data capture and sharing stage.Match the objectives to the description.Note: Answer may be used more than once. -​Maintain active medication list

Match each example of information to the part of the medical record in which it would be found. -Request-of-information letter from a patient's insurance company

Match each term with its definition. -These typically bear a disclaimer that states the report has or has not been reviewed for accuracy

Match each term with its definition. -Designated individual who keeps track of which individuals have access to protected health information within a facility

When filing records in a new file cabinet,it is recommended that you:

​Each filing system has pros and cons.Match the filing system to the "pros" description provided. -​Useful in community health environments

​Match the filing steps for medical records to the description. -​Step Four: put papers in alphabetical order

Which of the following is not an advantage of EHRs?

​Each filing system has pros and cons.Match the filing system to the "pros" description provided. -​Distributes files evenly over given spaces

Which of the following is an objective statement?

It is recommended that filing dividers or guides be constructed of _____ material.

​Which of the following would be a subjective statement?

The Medical Assistant

The Health Care Team and the Medical Environment,past and Present

Legal Issues

Ethical Issues

Verbal and Nonverbal Communications

Applying Communication Skills

Introduction to Medical Terminology

Understanding and Building Medical Terms of Body Systems

Anatomic Descriptors and Fundamental Body Structure

The Nervous System

The Senses

The Integumentary System

The Skeletal System

The Muscular System

The Respiratory System

The Circulatory System

The Immune System

The Digestive System

The Urinary System

The Endocrine System

The Reproductive System

Telephone Communications

Written Communications

The Office Environment, computers, and Equipment

Scheduling Appointments and Receiving Patients

Health Insurance

A Icd-10 Update: Procedural and Diagnostic Coding

Procedural and Diagnostic Coding

Patient Accounts

Preparing Insurance Claims and Posting Insurance Payments

Patient Billing,posting Patient Payments,and Collecting Fees

Banking Procedures

Accounts Payable and Accounting Procedures

Infection Control and Medical Asepsis

The Medical History and Patient Screening

Body Measurements and Vital Signs

Preparing for Examinations

The Physical Exam

Specialty Exams and Other Procedures

Obgyn Examinations

Pediatric Examinations

The Physicians Office Laboratory

Specimen Collection and Processing

Blood Specimen Collection

Diagnostic Testing

Cardiology Procedures

Radiology Procedures

Preparing for Surgery

Assisting With Minor Surgery

Pharmacology Fundamentals

Measurement Systems,basic Mathematics,and Dosage Calculations

Administering Oral and Non-Injectable Medications

Administering Injections and Immunizations

Emergencies in the Medical Office and the Community

First Aid for Accidents and Injuries

Rehabilitation

Nutrition,exercise,and Healthy Living

Practicum and the Job Search

Managing the Office

Filters

Stage 1 of meaningful use focuses on data capture and sharing stage.Match the objectives to the description.Note: Answer may be used more than once. -Implement drug-drug and drug-allergy interaction checks

Stage 1 of meaningful use focuses on data capture and sharing stage.Match the objectives to the description.Note: Answer may be used more than once. -Maintain active medication list

Each filing system has pros and cons.Match the filing system to the "pros" description provided. -Useful in community health environments

Match the filing steps for medical records to the description. -Step Four: put papers in alphabetical order

Each filing system has pros and cons.Match the filing system to the "pros" description provided. -Distributes files evenly over given spaces

Which of the following would be a subjective statement?