MA 500 Study Outline #2
What is the HIPAA privacy rule? - correct answers The acronym HIPAA stands for the Health Insurance
Portability and Accountability Act. It's a federal law to protect a patient's privacy.
What is the primary purpose of the rule? (HIPPA) - correct answers The primary purpose of this rule is to
provide patients with better control over the use and disclose of their health information.
What is the acronym for the progress note charting in the problem oriented record (POR)? - correct
answers The acronym for this method of documentation is SOAP, and this method of creating progress
notes is now widely used in all medical record formats.
What are the four categories of the SOAP progress note? Name them and what they each contain. -
correct answers• Subjective data: Subjective data obtained from the patient
• Objective data: Objective data obtained by observation, physical examination, and laboratory and
diagnostic tests
• Assessment: The physician's interpretation of the current condition based on analysis of the subjective
and objective data
• Plan: Proposed treatment for the patient
What does it mean for a medical assistant to witness a signature? - correct answers Witnessing a
signature means only that the medical assistant verified the patient's identity and watched the patient
sign the form.
What is a health history? - correct answersA collection of subjective data about the patient.
Before there is enough information, what terms might the physician use? - correct answersThe provider
uses terms such as medical impression, provisional diagnosis, preliminary diagnosis, or tentative
diagnosis.
, Lab reports contain what type of information? - correct answerslaboratory data obtained at the initial
visit and the physical examination findings are considered part of the database, whereas laboratory
reports related to specific problems are to be filed with other reports related to the problem.
What type of services are offered through home health care? - correct answersspecialized services
available through home health care include cardiac home care, intravenous (IV) therapy, respiratory
therapy, pain management, diabetes management, rehabilitation, and maternal-child care.
Physical therapy involves what? - correct answersPhysical therapy involves the use of therapeutic
exercise, thermal modalities, cold, hydrotherapy, electrical stimulation, massage, and other physical
agents to restore function and promote healing after an illness or injury.
Occupational therapy helps with what? - correct answersHelps a patient learn new skills to adapt to a
physically, developmentally, emotionally, or mentally disabling condition. This enables the patient to
perform activities of daily living and to achieve as much independence as possible.
Speech therapy refers to what? - correct answersSpeech therapy refers to treatment for the correction
of a speech impairment resulting from birth, disease, injury, or previous medical treatment.
Define inpatient - correct answersThe term inpatient refers to a patient who has been admitted to the
hospital for at least one overnight stay.
What is an operative report? - correct answersMust be completed for all patients who have undergone a
surgical procedure. This report describes the surgical procedure and must be completed and signed by
the surgeon who performed the operation.
What is a pathology report? - correct answersIf tissue was removed for microscopic examination, a
pathology report will also be generated.
What is the discharge summary report? - correct answersA brief (usually one-page) summary of the
significant events of a patient's hospitalization completed & signed by the attending physician.
What does a discharge summary include? - correct answersPatient's illness, course of treatment, and
response to treatment, and the condition of the patient at the time of discharge from the hospital.
What is the HIPAA privacy rule? - correct answers The acronym HIPAA stands for the Health Insurance
Portability and Accountability Act. It's a federal law to protect a patient's privacy.
What is the primary purpose of the rule? (HIPPA) - correct answers The primary purpose of this rule is to
provide patients with better control over the use and disclose of their health information.
What is the acronym for the progress note charting in the problem oriented record (POR)? - correct
answers The acronym for this method of documentation is SOAP, and this method of creating progress
notes is now widely used in all medical record formats.
What are the four categories of the SOAP progress note? Name them and what they each contain. -
correct answers• Subjective data: Subjective data obtained from the patient
• Objective data: Objective data obtained by observation, physical examination, and laboratory and
diagnostic tests
• Assessment: The physician's interpretation of the current condition based on analysis of the subjective
and objective data
• Plan: Proposed treatment for the patient
What does it mean for a medical assistant to witness a signature? - correct answers Witnessing a
signature means only that the medical assistant verified the patient's identity and watched the patient
sign the form.
What is a health history? - correct answersA collection of subjective data about the patient.
Before there is enough information, what terms might the physician use? - correct answersThe provider
uses terms such as medical impression, provisional diagnosis, preliminary diagnosis, or tentative
diagnosis.
, Lab reports contain what type of information? - correct answerslaboratory data obtained at the initial
visit and the physical examination findings are considered part of the database, whereas laboratory
reports related to specific problems are to be filed with other reports related to the problem.
What type of services are offered through home health care? - correct answersspecialized services
available through home health care include cardiac home care, intravenous (IV) therapy, respiratory
therapy, pain management, diabetes management, rehabilitation, and maternal-child care.
Physical therapy involves what? - correct answersPhysical therapy involves the use of therapeutic
exercise, thermal modalities, cold, hydrotherapy, electrical stimulation, massage, and other physical
agents to restore function and promote healing after an illness or injury.
Occupational therapy helps with what? - correct answersHelps a patient learn new skills to adapt to a
physically, developmentally, emotionally, or mentally disabling condition. This enables the patient to
perform activities of daily living and to achieve as much independence as possible.
Speech therapy refers to what? - correct answersSpeech therapy refers to treatment for the correction
of a speech impairment resulting from birth, disease, injury, or previous medical treatment.
Define inpatient - correct answersThe term inpatient refers to a patient who has been admitted to the
hospital for at least one overnight stay.
What is an operative report? - correct answersMust be completed for all patients who have undergone a
surgical procedure. This report describes the surgical procedure and must be completed and signed by
the surgeon who performed the operation.
What is a pathology report? - correct answersIf tissue was removed for microscopic examination, a
pathology report will also be generated.
What is the discharge summary report? - correct answersA brief (usually one-page) summary of the
significant events of a patient's hospitalization completed & signed by the attending physician.
What does a discharge summary include? - correct answersPatient's illness, course of treatment, and
response to treatment, and the condition of the patient at the time of discharge from the hospital.
