Question 1

Health information in any form that contains patient identifiable information is known as

Accepted Answer

A)  PHI. 
B)  NPP. 
C)  OSHA. 
D)  HIPAA. 
A)  PHI. 
B)  NPP. 
C)  OSHA. 
D)  HIPAA. A

Question 2

Laboratory tests ordered on a patient at an outside laboratory should be documented in the event which of the following occurs?

Accepted Answer

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. 
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. A

Question 3

What is a symptom?

Accepted Answer

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 
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 B

Question 4

All of the following are included in the social history except

Accepted Answer

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

Question 5

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

Accepted Answer

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

Question 6

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

Accepted Answer

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." 
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 7

What is the chief complaint?

Accepted Answer

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 
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 8

The purpose of the HIPAA Privacy Rule is to

Accepted Answer

A)  reduce exposure of patients to bloodborne pathogens. 
B)  provide patients with better 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. 
A)  reduce exposure of patients to bloodborne pathogens. 
B)  provide patients with better 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.

Question 9

Which of the following is an example of a consent document?

Accepted Answer

A)  Patient registration record 
B)  Notice of Privacy Practices form 
C)  Release of medical information form 
D)  Patient instruction sheet 
A)  Patient registration record 
B)  Notice of Privacy Practices form 
C)  Release of medical information form 
D)  Patient instruction sheet

Question 10

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

Accepted Answer

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 
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 11

The social history focuses on which of the following that may affect the patient's condition?

Accepted Answer

A)  Patient's lifestyle 
B)  Familial diseases 
C)  Past injuries 
D)  Medications being taken by the patient 
A)  Patient's lifestyle 
B)  Familial diseases 
C)  Past injuries 
D)  Medications being taken by the patient

Question 12

Why should a documentation error in a PPR never be erased or obliterated?

Accepted Answer

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

Question 13

The health history is taken

Accepted Answer

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

Question 14

In which of the following situations does HIPAA not require written consent for the use or disclosure of protected health information?

Accepted Answer

A)  Patient referral to a specialist 
B)  Emergency care provided at a hospital 
C)  Determination of eligibility for insurance benefits 
D)  Training of health care students 
E)  All of the above 
A)  Patient referral to a specialist 
B)  Emergency care provided at a hospital 
C)  Determination of eligibility for insurance benefits 
D)  Training of health care students 
E)  All of the above

Question 15

Which of the following is an example of a diagnostic procedure report?

Accepted Answer

A)  Electrocardiogram report 
B)  Physical therapy report 
C)  Urinalysis report 
D)  Pathology report 
A)  Electrocardiogram report 
B)  Physical therapy report 
C)  Urinalysis report 
D)  Pathology report

Question 16

All of the following must be performed when documenting in the medical record except:

Accepted Answer

A)  Check the name on the medical record before making an entry. 
B)  Include the patient's name at the beginning of each entry. 
C)  Begin each phrase with a capital letter and end with a period. 
D)  Never document for someone else. 
A)  Check the name on the medical record before making an entry. 
B)  Include the patient's name at the beginning of each entry. 
C)  Begin each phrase with a capital letter and end with a period. 
D)  Never document for someone else.

Question 17

Flushed skin usually indicates the patient

Accepted Answer

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

Question 18

What information is contained in the medical record?

Accepted Answer

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

Question 19

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

Accepted Answer

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

Question 20

What is an objective symptom?

Accepted Answer

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 
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

Exam 1: The Medical Record

Health information in any form that contains patient identifiable information is known as

Laboratory tests ordered on a patient at an outside laboratory should be documented in the event which of the following occurs?

What is a symptom?

All of the following are included in the social history except

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

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

What is the chief complaint?

The purpose of the HIPAA Privacy Rule is to

Which of the following is an example of a consent document?

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

The social history focuses on which of the following that may affect the patient's condition?

Why should a documentation error in a PPR never be erased or obliterated?

The health history is taken

In which of the following situations does HIPAA not require written consent for the use or disclosure of protected health information?

Which of the following is an example of a diagnostic procedure report?

All of the following must be performed when documenting in the medical record except:

Flushed skin usually indicates the patient

What information is contained in the medical record?

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

What is an objective symptom?

Medical Asepsis and the Osha Standard

Sterilization and Disinfection

Vital Signs

The Physical Examination

Eye and Ear Assessment and Procedures

Physical Agents to Promote Tissue Healing

The Gynecological Examination and Prenatal Care

The Pediatric Examination

Minor Office Surgery

Administration of Medication and Intravenous Therapy

Cardiopulmonary Procedures

Colon Procedures and Male Reproductive Health

Radiology and Diagnostic Imaging

Introduction to the Clinical Laboratory

Urinalysis

Phlebotomy

Hematology

Blood Chemistry and Immunology

Medical Microbiology

Nutrition

Emergency Preparedness and Protective Practices

Emergency Medical Procedures and First Aid

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