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bg MEDICAL ASSISTANTS 11TH EDITION/ALL CHAPTERS 1-
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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 bg
1. Which of the following is not a function of the clinical record?
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a. To provide information for making decisions regarding the patient’s care
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b. To document the patient’s progress
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c. To serve as a legal document bg bg bg bg bg
d. To share information between members of the patient’s family
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ACCURATE CHOICE:D REF: page. 2| CAAHEP Competency (2015): bg bg bg bg bg bg bg
VI.4OBJ: 1
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2. What information is contained in the clinical record?
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a. Health history report bg bg
b. Results of the physical examination bg bg bg bg
c. Laboratory reports bg
d. Progress notes bg
e. All of the above bg bg bg
ACCURATE CHOICE:E REF: page. 2-3| CAAHEP Competency (2015): bg bg bg bg bg bg bg
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. bg bg bg bg bg bg
b. provide patients with b e tte rNcUonRtS
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e Mand disclosure oftheir health
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bg information.
c. prevent the patient’s records from being copied. bg bg bg bg bg bg
d. encourage the patient to become more involved in preventive primary health care. bg bg bg bg bg bg bg bg bg bg bg
ACCURATE CHOICE: B REF: page. 4 | CAAHEP Competency (2015): bg bg b g b g bg bg bg bg bg
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 by the
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clinical office
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c. Must be provided to each patient bg bg bg bg bg
d. Must obtain a signed acknowledgment from the patient that he/she has received an
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NPP
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ACCURATE CHOICE:A REF: page. 4| CAAHEP Competency (2015): bg bg bg bg bg bg bg
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.
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IX.3OBJ: 2
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6. In which of the following situations does HIPAA not require written consent for the use or
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disclosure of protected health information?
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a. Patient referral to a specialist bg bg bg bg
b. Emergency care provided at a medical center bg bg bg bg bg bg
c. Determination of eligibility for insurance benefits bg bg bg bg bg
d. Training of primary health care students bg bg bg bg bg
e. All of the above bg bg bg
ACCURATE CHOICE:E REF: page. 4| CAAHEP Competency (2015): bg b g b g bg bg bg bg
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 bg bg
b. Physical examination report bg bg
c. Medication record bg
d. Health history report bg bg
ACCURATE CHOICE:A REF: page. 2-3| CAAHEP Competency bg bg b g bg bg bg
(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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d by an outside laboratory bg bg g
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ACCURATE CHOICE:D REF: page. 2-3| CAAHEP Competency bg bg b g bg bg bg
(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 bg
b. Physical therapy report bg bg
c. Urinalysis report bg
d. Pathology report bg
ACCURATE CHOICE:A REF: page. 2-3| CAAHEP Competency bg bg b g bg bg bg
(2015): VI.4OBJ: 2
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10. What is the name of the type of report that documents the assessments and treatments
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designed to restore a patient’s ability to function?
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a. Consultation report bg
b. Diagnostic procedure report bg bg
c. Pathology report bg
d. Therapeutic service report bg bg
ACCURATE CHOICE:D REF: page. 2-3| CAAHEP Competency bg bg b g bg bg bg
(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 bg
, b. Cytology report bg
c. Discharge summary report bg bg
d. Emergency department report bg bg
ACCURATE CHOICE:B bg
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 bg bg
b. Notice of Privacy Practices form bg bg bg bg
c. Release of clinical information form bg bg bg bg
d. Patient instruction sheet bg bg
ACCURATE CHOICE:C REF: page. 2-3| CAAHEP Competency bg b g b g bg bg bg
(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 bg bg bg bg
b. Storage of a clinical record bg bg bg bg
c. Editing of a clinical record bg bg bg bg
d. Retrieval of a clinical record bg bg bg bg
e. All of the above bg bg bg
ACCURATE CHOICE:E REF: page. 3| CAAHEP Competency (2015): bg b g b g bg bg bg bg
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.
b. documents in an EMR can N beUqRuS
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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. bg bg bg bg bg bg
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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 bg
b. Drop-down menus bg
c. Radio buttons bg
d. All of the above bg bg bg
ACCURATE CHOICE:D REF: page. 11| CAAHEP Competency (2015): bg bg bg bg bg bg bg
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 computerbg bg bg bg bg
b. By retyping them on the computer bg bg bg bg bg
c. By photocopying them bg bg
d. By transmitting them through a modem
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ACCURATE CHOICE:A REF: page. 11| CAAHEP Competency (2015): bg bg bg bg bg bg bg
VI.4OBJ: 8
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