Answers
Patient portal ANS an online application that allows patients to interact with and communicate
with their health care providers, e.g. secure e-mail within the EHR
What information is contained in the medical record? ANS health history/results of the physical
examination/laboratory reports/ progress report
What is the purpose of the HIPAA Privacy Rule? ANS provide patients with more control over
the use and disclosure of their health information
What is included in the patient registration record? ANS demographic and billing info
Which of the following provides subjective data about a patient to assist the physician in arriving at a
diagnosis? ANS health history
What is included on a medication record for medication administered at the office? ANS name of
medication/route of administration/dosage administered/number of refills
What type of report contains the results of the analysis of body specimens? ANS laboratory
report
What is NOT an example of a diagnostic report? ANS urinalysis report
What term is used to describe a patient who has been admitted to the hospital for at least one
overnight stay? ANS inpatient
What term might be used before there is enough information to make a definitive diagnosis? ANS
medical impression
, What report describes a surgical procedure? ANS operative report
Which of the following reports consists of an account of the significant events of a patient's
hospitalization? ANS discharge summary report
When a medical assistant witnesses a patient's signature, it means that he or she? ANS verified
the patients identity/watched the patient sign form
What can be performed by an electronic medical record software program? ANS creation,
storage, editing, and retrieval of any sort
In a source-oriented record, a radiology report is filed under which of the following chart dividers?
ANS lab/x-ray
The purpose of the tab on a file folder is to ANS identify the contents of the folder.
The health history is taken ANS before the physician performs the physical exam.
What is the chief complaint? ANS the symptom causing the patient the most trouble
What open-ended questions can be used to elicit the chief complaint from a patient? ANS What
seems to be the problem? How can we help you today? What brings you to the doctor today?
An expansion of the chief complaint is know as the ANS present illness
What term is used to describe the process of making written entries about a patient in the medical
record? ANS charting
Why should black ink be used when recording in the patient's paper medical record? ANS
provide a permanent record; easier to reproduce