,Chapter il01: ilThe ilMedical ilRecord
Bonewit-West: ilClinical ilProcedures ilfor ilMedical ilAssistants, il10th ilEdition
MULTIPLE ilCHOICE
1. Which ilof ilthe ilfollowing ilis ilnot ila ilfunction ilof ilthe ilmedical ilrecord?
a. To ilprovide ilinformation ilfor ilmaking ildecisions ilregarding ilthe ilpatient’s ilcare
b. To ildocument ilthe ilpatient’s ilprogress
c. To ilserve ilas ila illegal ildocument
d. To ilshare ilinformation ilbetween ilmembers ilof ilthe ilpatient’s ilfamily
ANS: i l D REF: ilp. il2| ilCAAHEP ilCompetency il(2015):
ilVI.4liOBJ: il 1
2. What ilinformation ilis ilcontained ilin ilthe ilmedical ilrecord?
a. Health ilhistory ilreport
b. Results ilof ilthe ilphysical ilexamination
c. Laboratory ilreports
d. Progress ilnotes
e. All ilof ilthe ilabove
ANS: i l E REF: ilpp. il2-3| ilCAAHEP ilCompetency il(2015):
ilVI.4liOBJ: il 2
3. The ilpurpose ilof ilthe ilHIPAA ilPrivacy ilRule ilis ilto
a. reduce ilexposure ilof ilpatients ilto ilbloodborne ilpathogens.
b. provide ilpatients ilwith ilbetterNcU
onRtSroI
l ilN
ovGeT
r iltB
he.C
usO
eMand ildisclosure ilof iltheir
ilhealth ilinformation.
c. prevent ilthe ilpatient’s ilrecords ilfrom ilbeing ilcopied.
d. encourage ilthe ilpatient ilto ilbecome ilmore ilinvolved ilin ilpreventive ilhealth ilcare.
ANS: i l B REF: ilp. il4 il| ilCAAHEP ilCompetency il(2015):
ilIX.3liOBJ: il 2
4. All ilof ilthe ilfollowing ilare ilcharacteristics ilof ilthe ilNotice ilof ilPrivacy ilPractices il except:
a. Was ildeveloped ilby ilthe ilAmerican ilMedical ilAssociation
b. Must ilexplain ilhow ila ilpatient’s ilhealth ilinformation ilwill ilbe ilused iland
ilprotected ilby ilthelm
i edical iloffice
c. Must ilbe ilprovided ilto ileach ilpatient
d. Must ilobtain ila ilsigned ilacknowledgment ilfrom ilthe ilpatient ilthat ilhe/she ilhas
ilreceived ilanlN
i PP
ANS: i l A REF: ilp. il4| ilCAAHEP ilCompetency il(2015):
ilIX.3liOBJ: il 2
5. Health ilinformation ilin ilany ilform ilthat ilcontains ilpatient ilidentifiable ilinformation ilis ilknown ilas
a. PHI.
b. NPP.
c. OSHA.
d. HIPAA.
, ANS: i l A REF: ilp. il4| ilCAAHEP ilCompetency il(2015):
ilIX.3liOBJ: il 2
6. In ilwhich ilof ilthe ilfollowing ilsituations ildoes ilHIPAA ilnot ilrequire ilwritten ilconsent ilfor
ilthe iluse ilorld
i isclosure ilof ilprotected ilhealth ilinformation?
a. Patient ilreferral ilto ila ilspecialist
b. Emergency ilcare ilprovided ilat ila ilhospital
c. Determination ilof ileligibility ilfor ilinsurance ilbenefits
d. Training ilof ilhealth ilcare ilstudents
e. All ilof ilthe ilabove
ANS: i l E REF: ilp. il4| ilCAAHEP ilCompetency il(2015):
ilIX.3liOBJ: il 2
7. Which ilof ilthe ilfollowing ilis ilnot ilan ilexample ilof ila ilmedical iloffice ilclinical ildocument?
a. Patient ilregistration ilrecord
b. Physical ilexamination ilreport
c. Medication ilrecord
d. Health ilhistory ilreport
ANS: i l A REF: ilpp. il2-3| ilCAAHEP ilCompetency il(2015):
ilVI.4liOBJ: il 2
8. Which ilof ilthe ilfollowing ilis ilnot ila ilcharacteristic ilof ila illaboratory ilreport?
a. It ilrelays ilresults ilof illaboratory iltests ilto ilthe ilprovider
b. It ilconsists ilof ila ilreport ilof ilthe ilanalysis ilor ilexamination ilof ilbody ilspecimens
c. It ilassists ilin ildiagnosing iland iltreating ildisease
d. It ilis ila ilrequest ilfor illaboratoryNtU esRtsStI
oilN
beGpTeB
rf.
orCmOeM
d ilby ilan iloutside illaboratory
ANS: i l D REF: ilpp. il2-3| ilCAAHEP ilCompetency il(2015):
ilVI.4liOBJ: il 2
9. Which ilof ilthe ilfollowing ilis ilan ilexample ilof ila ildiagnostic ilprocedure ilreport?
a. Electrocardiogram ilreport
b. Physical iltherapy ilreport
c. Urinalysis ilreport
d. Pathology ilreport
ANS: i l A REF: ilpp. il2-3| ilCAAHEP ilCompetency il(2015):
ilVI.4liOBJ: il 2
10. What ilis ilthe ilname ilof ilthe iltype ilof ilreport ilthat ildocuments ilthe ilassessments iland
i esigned ilto ilrestore ila ilpatient’s ilability ilto ilfunction?
iltreatmentsld
a. Consultation ilreport
b. Diagnostic ilprocedure ilreport
c. Pathology ilreport
d. Therapeutic ilservice ilreport
ANS: i l D REF: ilpp. il2-3| ilCAAHEP ilCompetency il(2015):
ilVI.4liOBJ: il 2
11. Which ilof ilthe ilfollowing ilis ilnot ilan ilexample ilof ila ilhospital ilreport?
a. Operative ilreport
, b. Cytology ilreport
c. Discharge ilsummary ilreport
d. Emergency ildepartment ilreport
ANS: i l B REF: ilpp. il2-3| ilCAAHEP ilCompetency il(2015):
ilVI.4liOBJ: il 2
12. Which ilof ilthe ilfollowing ilis ilan ilexample ilof ila ilconsent ildocument?
a. Patient ilregistration ilrecord
b. Notice ilof ilPrivacy ilPractices ilform
c. Release ilof ilmedical ilinformation ilform
d. Patient ilinstruction ilsheet
ANS: i l C REF: ilpp. il2-3| ilCAAHEP ilCompetency il(2015):
ilVI.4liOBJ: il 2
13. Which ilof ilthe ilfollowing ilcan ilbe ilperformed ilby ilan ilelectronic ilmedical ilrecord ilsoftware
ilprogram?
a. Creation ilof ila ilmedical ilrecord
b. Storage ilof ila ilmedical ilrecord
c. Editing ilof ila ilmedical ilrecord
d. Retrieval ilof ila ilmedical ilrecord
e. All ilof ilthe ilabove
ANS: i l E REF: ilp. il3| ilCAAHEP ilCompetency il(2015):
ilV.8liOBJ: il 3
14. All ilof ilthe ilfollowing ilare iladvantages ilof ilan ilelectronic ilmedical ilrecord il(EMR) il except
a. an ilEMR ildoes ilnot ilhave ilto ilbe ilfiled.
b. documents ilin ilan ilEMR ilcan ilN beUqRuS
icI
klNyGreTtrBie.vC
edO. ilM
c. more ilthan ilone ilperson ilcan ilview ilan ilEMR ilat ilthe ilsame iltime.
d. EMRs ilare ilexempt ilfrom ilthe ilHIPAA ilregulations.
ANS: i l D REF: ilpp. il3, il6| ilCAAHEP ilCompetency il(2015):
ilVI.12lO
i BJ: il 5
15. Which ilof ilthe ilfollowing ilare ilused ilto ilenter ildata ilinto ilan ilelectronic ilmedical ilrecord?
a. Free-text ilentry
b. Drop-down ilmenus
c. Radio ilbuttons
d. All ilof ilthe ilabove
ANS: i l D REF: ilp. il11| ilCAAHEP ilCompetency il(2015):
ilV.8liOBJ: il 8
16. How ilare ilpaper ildocuments ilentered ilinto ila ilpatient’s ilelectronic ilmedical ilrecord?
a. By ilscanning ilthem ilinto ilthe ilcomputer
b. By ilretyping ilthem ilon ilthe ilcomputer
c. By ilphotocopying ilthem
d. By iltransmitting ilthem ilthrough ila ilmodem
ANS: i l A REF: ilp. il11| ilCAAHEP ilCompetency il(2015):
ilVI.4liOBJ: il 8
Bonewit-West: ilClinical ilProcedures ilfor ilMedical ilAssistants, il10th ilEdition
MULTIPLE ilCHOICE
1. Which ilof ilthe ilfollowing ilis ilnot ila ilfunction ilof ilthe ilmedical ilrecord?
a. To ilprovide ilinformation ilfor ilmaking ildecisions ilregarding ilthe ilpatient’s ilcare
b. To ildocument ilthe ilpatient’s ilprogress
c. To ilserve ilas ila illegal ildocument
d. To ilshare ilinformation ilbetween ilmembers ilof ilthe ilpatient’s ilfamily
ANS: i l D REF: ilp. il2| ilCAAHEP ilCompetency il(2015):
ilVI.4liOBJ: il 1
2. What ilinformation ilis ilcontained ilin ilthe ilmedical ilrecord?
a. Health ilhistory ilreport
b. Results ilof ilthe ilphysical ilexamination
c. Laboratory ilreports
d. Progress ilnotes
e. All ilof ilthe ilabove
ANS: i l E REF: ilpp. il2-3| ilCAAHEP ilCompetency il(2015):
ilVI.4liOBJ: il 2
3. The ilpurpose ilof ilthe ilHIPAA ilPrivacy ilRule ilis ilto
a. reduce ilexposure ilof ilpatients ilto ilbloodborne ilpathogens.
b. provide ilpatients ilwith ilbetterNcU
onRtSroI
l ilN
ovGeT
r iltB
he.C
usO
eMand ildisclosure ilof iltheir
ilhealth ilinformation.
c. prevent ilthe ilpatient’s ilrecords ilfrom ilbeing ilcopied.
d. encourage ilthe ilpatient ilto ilbecome ilmore ilinvolved ilin ilpreventive ilhealth ilcare.
ANS: i l B REF: ilp. il4 il| ilCAAHEP ilCompetency il(2015):
ilIX.3liOBJ: il 2
4. All ilof ilthe ilfollowing ilare ilcharacteristics ilof ilthe ilNotice ilof ilPrivacy ilPractices il except:
a. Was ildeveloped ilby ilthe ilAmerican ilMedical ilAssociation
b. Must ilexplain ilhow ila ilpatient’s ilhealth ilinformation ilwill ilbe ilused iland
ilprotected ilby ilthelm
i edical iloffice
c. Must ilbe ilprovided ilto ileach ilpatient
d. Must ilobtain ila ilsigned ilacknowledgment ilfrom ilthe ilpatient ilthat ilhe/she ilhas
ilreceived ilanlN
i PP
ANS: i l A REF: ilp. il4| ilCAAHEP ilCompetency il(2015):
ilIX.3liOBJ: il 2
5. Health ilinformation ilin ilany ilform ilthat ilcontains ilpatient ilidentifiable ilinformation ilis ilknown ilas
a. PHI.
b. NPP.
c. OSHA.
d. HIPAA.
, ANS: i l A REF: ilp. il4| ilCAAHEP ilCompetency il(2015):
ilIX.3liOBJ: il 2
6. In ilwhich ilof ilthe ilfollowing ilsituations ildoes ilHIPAA ilnot ilrequire ilwritten ilconsent ilfor
ilthe iluse ilorld
i isclosure ilof ilprotected ilhealth ilinformation?
a. Patient ilreferral ilto ila ilspecialist
b. Emergency ilcare ilprovided ilat ila ilhospital
c. Determination ilof ileligibility ilfor ilinsurance ilbenefits
d. Training ilof ilhealth ilcare ilstudents
e. All ilof ilthe ilabove
ANS: i l E REF: ilp. il4| ilCAAHEP ilCompetency il(2015):
ilIX.3liOBJ: il 2
7. Which ilof ilthe ilfollowing ilis ilnot ilan ilexample ilof ila ilmedical iloffice ilclinical ildocument?
a. Patient ilregistration ilrecord
b. Physical ilexamination ilreport
c. Medication ilrecord
d. Health ilhistory ilreport
ANS: i l A REF: ilpp. il2-3| ilCAAHEP ilCompetency il(2015):
ilVI.4liOBJ: il 2
8. Which ilof ilthe ilfollowing ilis ilnot ila ilcharacteristic ilof ila illaboratory ilreport?
a. It ilrelays ilresults ilof illaboratory iltests ilto ilthe ilprovider
b. It ilconsists ilof ila ilreport ilof ilthe ilanalysis ilor ilexamination ilof ilbody ilspecimens
c. It ilassists ilin ildiagnosing iland iltreating ildisease
d. It ilis ila ilrequest ilfor illaboratoryNtU esRtsStI
oilN
beGpTeB
rf.
orCmOeM
d ilby ilan iloutside illaboratory
ANS: i l D REF: ilpp. il2-3| ilCAAHEP ilCompetency il(2015):
ilVI.4liOBJ: il 2
9. Which ilof ilthe ilfollowing ilis ilan ilexample ilof ila ildiagnostic ilprocedure ilreport?
a. Electrocardiogram ilreport
b. Physical iltherapy ilreport
c. Urinalysis ilreport
d. Pathology ilreport
ANS: i l A REF: ilpp. il2-3| ilCAAHEP ilCompetency il(2015):
ilVI.4liOBJ: il 2
10. What ilis ilthe ilname ilof ilthe iltype ilof ilreport ilthat ildocuments ilthe ilassessments iland
i esigned ilto ilrestore ila ilpatient’s ilability ilto ilfunction?
iltreatmentsld
a. Consultation ilreport
b. Diagnostic ilprocedure ilreport
c. Pathology ilreport
d. Therapeutic ilservice ilreport
ANS: i l D REF: ilpp. il2-3| ilCAAHEP ilCompetency il(2015):
ilVI.4liOBJ: il 2
11. Which ilof ilthe ilfollowing ilis ilnot ilan ilexample ilof ila ilhospital ilreport?
a. Operative ilreport
, b. Cytology ilreport
c. Discharge ilsummary ilreport
d. Emergency ildepartment ilreport
ANS: i l B REF: ilpp. il2-3| ilCAAHEP ilCompetency il(2015):
ilVI.4liOBJ: il 2
12. Which ilof ilthe ilfollowing ilis ilan ilexample ilof ila ilconsent ildocument?
a. Patient ilregistration ilrecord
b. Notice ilof ilPrivacy ilPractices ilform
c. Release ilof ilmedical ilinformation ilform
d. Patient ilinstruction ilsheet
ANS: i l C REF: ilpp. il2-3| ilCAAHEP ilCompetency il(2015):
ilVI.4liOBJ: il 2
13. Which ilof ilthe ilfollowing ilcan ilbe ilperformed ilby ilan ilelectronic ilmedical ilrecord ilsoftware
ilprogram?
a. Creation ilof ila ilmedical ilrecord
b. Storage ilof ila ilmedical ilrecord
c. Editing ilof ila ilmedical ilrecord
d. Retrieval ilof ila ilmedical ilrecord
e. All ilof ilthe ilabove
ANS: i l E REF: ilp. il3| ilCAAHEP ilCompetency il(2015):
ilV.8liOBJ: il 3
14. All ilof ilthe ilfollowing ilare iladvantages ilof ilan ilelectronic ilmedical ilrecord il(EMR) il except
a. an ilEMR ildoes ilnot ilhave ilto ilbe ilfiled.
b. documents ilin ilan ilEMR ilcan ilN beUqRuS
icI
klNyGreTtrBie.vC
edO. ilM
c. more ilthan ilone ilperson ilcan ilview ilan ilEMR ilat ilthe ilsame iltime.
d. EMRs ilare ilexempt ilfrom ilthe ilHIPAA ilregulations.
ANS: i l D REF: ilpp. il3, il6| ilCAAHEP ilCompetency il(2015):
ilVI.12lO
i BJ: il 5
15. Which ilof ilthe ilfollowing ilare ilused ilto ilenter ildata ilinto ilan ilelectronic ilmedical ilrecord?
a. Free-text ilentry
b. Drop-down ilmenus
c. Radio ilbuttons
d. All ilof ilthe ilabove
ANS: i l D REF: ilp. il11| ilCAAHEP ilCompetency il(2015):
ilV.8liOBJ: il 8
16. How ilare ilpaper ildocuments ilentered ilinto ila ilpatient’s ilelectronic ilmedical ilrecord?
a. By ilscanning ilthem ilinto ilthe ilcomputer
b. By ilretyping ilthem ilon ilthe ilcomputer
c. By ilphotocopying ilthem
d. By iltransmitting ilthem ilthrough ila ilmodem
ANS: i l A REF: ilp. il11| ilCAAHEP ilCompetency il(2015):
ilVI.4liOBJ: il 8
