NCCT Practice exam

NCCT Practice exam For how many years should a provider store medical records (select the least number of years that maintains compliance with state and federal regulations)? A. 15 years B. 10 years C. 5 years D. 20 years Correct response: 10 years Rationale: Federal and state regulations require a minimum storage time frame for medical records. State regulations may require a longer or shorter time frame, depending on the state. Every medical provider should routinely check state and federal requirements to remain compliant. As of the date this question was submitted (2015), a 7 to 10 year time frame would meet all federal and state medical record storage requirements. Flow charts, progress notes, and narrative notation are all examples of A. medical record charting styles. B. patient documentation in a SOAP format. C. recording patient information in a medical record. D. patient chart filing systems. Correct response: recording patient information in a medical record. Rationale: Patient information can be recorded in the medical record in a variety of ways. Progress notes, flow charts and narrative notation are all effective ways to document a patient's medical information. The SOAP format is the documentation system chosen by many physicians. S=Subjective patient interview information, O=Objective information such as vitals, lab values, etc., A=Assessment of the "S" and "O" data, P=Plan for treatment or follow-up. Medical records of various styles are generally kept in charts, which are filed according to a filing system. When measuring oxygen saturation on a child breathing room air, with normal color, and no signs of respiratory distress, the medical assistant obtains a reading of 79%. Which of the following actions should the medical assistant take next? A. supplement the child with oxygen per protocol B. take a full set of vital signs C. reposition the finger probe D. notify the physician Correct response: reposition the finger probe Rationale: Oxygen saturation (O2 Sat or Pulse Ox) on a child with a structurally normal heart should be 92% . Patient movement, poor probe attachment, or nail polish can distort the sensor reading during monitoring. Always observe the child's condition first, and machine reading 2nd when troubleshooting. O2 saturation should be obtained and documented as part of a full set of vital signs for patients being evaluated for respiratory conditions. Which of the following is the best way to correct AC interference on an ECG? A. Ask the patient not to move while performing the test. B. Move the patient to a quiet room. C. Check that the patient does not have a cell phone close by. D. Offer the patient a blanket if she is cold. Correct response: Check that the patient does not have a cell phone close by. Rationale: AC is alternating current interference and it can be caused by a nearby electrical device (such as a cell phone). Patient movement (either voluntary or shivering from the cold) can cause other artifact on an ECG, but not the same as AC interference. Moving the patient to a quiet room would not alleviate AC interference. Which of the following documents is also called an advanced directive? A. subpoena B. informed consent C. living will D. assignment of benefits Correct response: living will Rationale: A living will is a formal document, written in advance, that gives health care professionals instructions about the patient's medical wishes regarding end of life care, and is the same as an advanced directive. Assignment of benefits refers to the patient's wishes on who and where they want their money sent to, a subpoena is an order given to someone who is supposed to go to court, and informed consent refers to a document that a patient fills out which gives permission to the healthcare providers to perform certain tasks or procedures. Beginning with the infectious agent, place the elements in the correct order of the chain of infection. (Click and drag the options in the left column to their correct order in the right column). reservoir host portal of exit means of transmission portal of entry susceptible host Correct response: reservoir host, portal of exit, means of transmission, portal of entry, susceptible host Rationale: Infectious diseases are spread through a series of steps known as the "chain of infection". For an infection to occur and spread, each of the six links of the chain must take place. Removing any link in the chain will stop the cycle. Therefore, identifying and instituting appropriate actions at different steps in the cycle will halt the spread of the infection. The chain begins with the infectious agent (bacteria, virus,etc.) and spreads to a reservoir (place to live, like an animal, insect, water, etc.). The portal of exit is a way for the microorganism to leave the reservoir (in a cough, feces, etc.) to transmit the disease. The mode of infection refers to how infectious diseases are spread: by contact, by vehicle, by vector, and by inhalation. The infectious agent enters a susceptible host through a portal of entry.Correct response: reservoir host, portal of exit, means of transmission, portal of entry, susceptible host Rationale: Infectious diseases are spread through a series of steps known as the "chain of infection". For an infection to occur and spread, each of the six links of the chain must take place. Removing any link in the chain will stop the cycle. Therefore, identifying and instituting appropriate actions at different steps in the cycle will halt the spread of the infection. The chain begins with the infectious agent (bacteria, virus,etc.) and spreads to a reservoir (place to live, like an animal, insect, water, etc.). The portal of exit is a way for the microorganism to leave the reservoir (in a cough, feces, etc.) to transmit the disease. The mode of infection refers to how infectious diseases are spread: by contact, by vehicle, by vector, and by inhalation. The infectious agent enters a susceptible host through a portal of entry. The medical assistant schedules a follow-up appointment for a patient following surgical removal of their uterus. The medical term for this procedure is A. amniocentesis. B. oophorectomy. C. uteroscopy. D. hysterectomy Correct response: hysterectomy. Rationale: The definition of a Hysterectomy is Hyster- = uterus, ectomy = surgical removal of. An Oophorectomy is the surgical removal of an ovary or ovaries, an Ureteroscopy is an examination of the upper urinary tract, and Amniocentesis is a test used to determine whether an unborn baby has any genetic abnormalities. When inspecting a patient's arm before performing a venipuncture, the most desirable site appears to be the back of the hand. Which of the following venipuncture methods is most appropriate in this situation? A. butterfly needle B. capillary puncture C. needle and syringe D. evacuated tube Correct response: butterfly needle Rationale: The best choice in this situation is to use a butterfly needle, a winged needle with flexible tubing that is short in length. Butterfly needles are easier to insert into tiny, fragile, and/or rolling surface veins close to the skin. If a butterfly is not available, a needle and syringe would be the next choice. The vacuum pressure of evacuated tubes can collapse small or fragile veins such as those on the back of the hand. A capillary puncture would be the last option here, and would be used in the instance of a failed butterfly or syringe attempt (provided there are no other veins available). A medical assistant is positioning a patient for sigmoidoscopy. Which of the following positions would be appropriate for the procedure? A. supine B. Trendelenburg C. lithotomy D. Sims Correct response: Sims Rationale: For a sigmoidoscopy, the patient will need to lie on the left side with the right knee bent, which is also referred to as the Sims position. This allows the physician to insert the sigmoidoscope through the anus to the colon to get a clear look at the area. The lithotomy position is when the patient lies on their back with the thighs spread apart and the hips and knees bent. This position is mostly used for vaginal examinations and childbirth, and would not be the best position for a sigmoidoscopy. The Trendelenburg position is when the patient lies flat on their back with the feet elevated higher than the head by 15-30 degrees, and the supine position is achieved when the patient is lying flat on their back with no part of the body elevated. The Trendelenburg and supine positions would not typically be used for a sigmoidoscopy, because if the patient is lying on their back it does not allow the physician to easily insert the sigmoidoscope into the anus to get a clear view of the sigmoid colon. An established patient who has Chronic Obstructive Pulmonary Disease is evaluated in the medical office for hypertension. What is the importance of identifying the reason for today's visit related to billing? A. to assign a two-digit modifier B. to assign a V code C. to determine the primary diagnosis D. to ensure a secondary diagnosis is not listed on the claim form Correct response: to determine the primary diagnosis Rationale: In this example, hypertension should be listed as the primary diagnosis (main reason the patient sought care for visit) and COPD as secondary (this will disease will be considered when medications are prescribed for HTN.) A large open container of isopropyl alcohol is spilled on the floor in the clinic waiting area. The medical office assistant should use which of the following resources for information about the chemical and any necessary procedure? A. Poison Control Center B. Physician's Desk Reference C. Material Safety Data Sheet D. Clinical Laboratory Improvement Amendments Correct response: Material Safety Data Sheet Rationale: Access to Material Safety Data Sheets is an OSHA compliance requirement. Each MSDS contains information on the potential hazards (health, fire, reactivity and environmental) and how to work safely with chemical products. It is an essential starting point for the development of a complete health and safety program. Clinical Laboratory Improvement Amendments (CLIA) of 1988 are United States federal regulatory standards that apply to all clinical laboratory testing performed on humans in the United States, except clinical trials and basic research. A poison control center is a medical facility that is able to provide immediate, free, and expert treatment advice and assistance over the telephone in case of exposure to poisonous or hazardous substances. The purpose of the Physician's Desk Reference is to provide a compendium compiled annually, containing information supplied by drug manufacturers about drugs, primarily prescription drugs and products used in diagnostic procedures in the United States. A Material Safety Data Sheet includes information such as physical,