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MEDICAL ASSISTANTS 11TH EDITION/ALL CHAPTERS
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1-23/COMPLETE GUIDE 2024-2025
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,CH 01: The Clinical Record
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Bonewit-West: Clinical Procedures for Clinical Assistants, 11th Edition
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MULTIPLE CHOICE vb
1. Which vbof the following is not a function of the clinical record?
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a. To vbprovide information for making decisions regarding the patient’s care
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b. To vbdocument the patient’s progress vb vb vb
c. To vbserve as a legal document vb vb vb vb
d. To vbshare information between members of the patient’s family
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ACCURATE CHOICE:D REF: page. 2| CAAHEP Competency vb vb vb vb vb vb
(2015): VI.4OBJ: 1
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2. What information is contained in the clinical record?
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a. Health history report vb vb
b. Results of the physical examination vb vb vb vb
c. Laboratory reports vb
d. Progress notes vb
e. All of the above vb vb vb
ACCURATE CHOICE:E REF: page. 2-3| CAAHEP Competency vb vb vb vb vb vb
(2015): VI.4OBJ: 2
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3. The purpose of the HIPAA Privacy Rule is to
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a. reduce exposure of patients to bloodborne pathogens.
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b. provide patients with be t t e rNcUo nRt S
r oIl N
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r tBhe.C
usO
e Ma nd disclosure of their
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health information.
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c. prevent the patient’s records from being copied.
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d. encourage the patient to become more involved in preventive primary health care.
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ACCURATE CHOICE: B REF: page. 4 | CAAHEP Competency vb vb vb v b vb vb vb vb
(2015): IX.3OBJ: 2
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4. All of the following are characteristics of the Notice of Privacy Practices except:
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a. Was developed by the American Clinical Association
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b. Must explain how a patient’s health information will be used and protected
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vb by theclinical office
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c. Must be provided to each patient vb vb vb vb vb
d. Must obtain a signed acknowledgment from the patient that he/she has
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ACCURATE CHOICE:A REF: page. 4| CAAHEP Competency vb vb vb vb vb vb
(2015): IX.3OBJ: 2
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5. Health information in any form that contains patient identifiable information is known as
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a. PHI.
b. NPAGE.
c. OSHA.
d. HIPAA.
, ACCURATE CHOICE:A REF: page. 4| CAAHEP Competency
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(2015): IX.3OBJ: 2
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6. In which of the following situations does HIPAA not require written consent for the
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use ordisclosure of protected health information?
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a. Patient referral to a specialist vb vb vb vb
b. Emergency care provided at a medical center vb vb vb vb vb vb
c. Determination of eligibility for insurance benefits vb vb vb vb vb
d. Training of primary health care students vb vb vb vb vb
e. All of the above vb vb vb
ACCURATE CHOICE:E REF: page. 4| CAAHEP Competency
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(2015): IX.3OBJ: 2
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7. Which of the following is not an example of a clinical office clinical document?
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a. Patient registration record vb vb
b. Physical examination report vb vb
c. Medication record vb
d. Health history report vb vb
ACCURATE CHOICE:A REF: page. 2-3| CAAHEP Competency
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(2015): VI.4OBJ: 2
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8. Which of the following is not a characteristic of a laboratory report?
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a. It relays results of laboratory tests to the provider
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b. It consists of a report of the analysis or examination of body specimens
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c. It assists in diagnosing and treating sickness
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d. It is a request for laboratoryNtU
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oNbeGpTeBrf.
orCmOeM
d by an outside laboratory
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ACCURATE CHOICE:D REF: page. 2-3| CAAHEP Competency
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(2015): VI.4OBJ: 2
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9. Which of the following is an example of a diagnostic procedure report?
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a. Electrocardiogram report vb
b. Physical therapy report vb vb
c. Urinalysis report vb
d. Pathology report vb
ACCURATE CHOICE:A REF: page. 2-3| CAAHEP Competency
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(2015): VI.4OBJ: 2
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10. What is the name of the type of report that documents the assessments and
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treatmentsdesigned to restore a patient’s ability to function?
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a. Consultation report vb
b. Diagnostic procedure report vb vb
c. Pathology report vb
d. Therapeutic service report vb vb
ACCURATE CHOICE:D REF: page. 2-3| CAAHEP Competency
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(2015): VI.4OBJ: 2
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11. Which of the following is not an example of a medical center report?
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a. Operative report vb
, b. Cytology report vb
c. Discharge summary report vb vb
d. Emergency department report vb vb
ACCURATE CHOICE:B vb
REF: page. 2-3| CAAHEP Competency (2015): VI.4 OBJ:
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12. Which of the following is an example of a consent document?
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a. Patient registration record vb vb
b. Notice of Privacy Practices form vb vb vb vb
c. Release of clinical information form vb vb vb vb
d. Patient instruction sheet vb vb
ACCURATE CHOICE:C REF: page. 2-3| CAAHEP Competencyvb vb v b vb vb vb
(2015): VI.4OBJ: 2
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13. Which of the following can be performed by an electronic clinical record software program?
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a. Creation of a clinical record vb vb vb vb
b. Storage of a clinical record vb vb vb vb
c. Editing of a clinical record vb vb vb vb
d. Retrieval of a clinical record vb vb vb vb
e. All of the above vb vb vb
ACCURATE CHOICE:E REF: page. 3| CAAHEP Competency vb v b vb vb vb vb
(2015): V.8OBJ: 3
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14. All of the following are advantages of an electronic clinical record (EMR) except
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a. an EMR does not have to be filed.
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b. documents in an EMR can N URSIN GTB.C OM
be quick ly retrieved. vb vb vb vb vb vb
c. more than one person can view an EMR at the same time.
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d. EMRs are exempt from the HIPAA regulations.
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ACCURATE CHOICE:D REF: page. 3, 6| CAAHEP Competency
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(2015): VI.12OBJ: 5
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15. Which of the following are used to enter data into an electronic clinical record?
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a. Free-text entry vb
b. Drop-down menus vb
c. Radio buttons vb
d. All of the above vb vb vb
ACCURATE CHOICE:D REF: page. 11| CAAHEP Competency vb vb vb vb vb vb
(2015): V.8OBJ: 8
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16. How are paper documents entered into a patient’s electronic clinical record?
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a. By scanning them into the computer
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b. By retyping them on the computer
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c. By photocopying them
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d. By transmitting them through a modem
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ACCURATE CHOICE:A REF: page. 11| CAAHEP Competency vb vb vb vb vb vb
(2015): VI.4OBJ: 8
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