MA500 exam 2 Practice Exam Questions And Correct Detailed Answers.

What is the HIPAA privacy rule? - correct answers-protects individuals' medical records and other personal health information, including transfer of electronic records -sets limits and conditions on the uses and disclosures allowed without patient authorization - only necessary information is disclosed -gives patients rights concerning the examination and copying of their health records and to request corrections What is the primary purpose of the HIPAA privacy rule? - correct answersto rectrict the circumstances in which an individual's protected health info may be used. What is the acronym for the progress note charting in the problem oriented record (POR)? - correct answersProblem Oriented Record What are the four categories of the SOAP progress note? Name them and what they each contain. - correct answersSubject data, objective data, assessment, plan What does it mean for a medical assistant to witness a signature? - correct answersonly that the medical assistant verified the patient's identity and watched the patient sign the form; it does not mean that the medical assistant is attesting to the accuracy of the information provided. What is a health history? - correct answersA collection of subjective data that provides a detailed profile of the patient's health status Before there is enough health history information, what terms might the physician use? - correct answersmedical impression, provisional diagnosis, preliminary diagnosis, or tentative diagnosis Lab reports contain what type of information? - correct answersspecific problems are to be filed with other reports related to the problem What is a consultation report? - correct answersA narrative report of a clinical opinion about a patient's condition by a practitioner other than the primary physician, known as a consultant. The consultant is usually a specialist in a certain field of medicine What type of services are offered through home health care? - correct answers•Observations and evaluations • Type of care or service provided • Instructions given to the patient on medications • Safety measures recommended for the home • Diet • Activities permitted Phvsical therapv involves what? - correct answersinvolves 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 answersrefers to treatment for the correction of a speech impairment resulting from birth, disease, injury, or previous medical treatment. define inpatient - correct answersInpatient is a person who is admitted to the hospital and stays overnight or for an indeterminate amount of time, usually several days or weeks. 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 answersreport containing a description of tissue samples removed from the body What is the discharge summary report? - correct answersReport that is required for all patients who leave the health care facility summarizing patient's condition during his/her stay. What is the chief complaint (CC)? - correct answersidentifies the patient's reason for seeking care—that is, the symptom that is causing the patient the most trouble. What are the guidelines in obtaining and recording the CC? - correct answers•An open-ended question should be used to elicit the CC from the patient: What seems to be the problem? How can we help you today? What brings you to the doctor today? • The CC should be limited to one or two symptoms and should refer to a specific rather than a vague symptom. • The CC should be recorded concisely and briefly, using the patient's own words as much as possible. • The duration of the symptom (onset) should be included in the CC. • The medical assistant should avoid using names of diseases or diagnostic terms to record the CC. What is the past medical history? - correct answersThe patient's previous diseases, injuries, and operations What is family history? - correct answersReview of health status of patient's blood relatives What is the Review of Systems (ROS)? - correct answersA systematic review of each body system What are the five guidelines for documenting in a patient's record? - correct answersCheck the name and date of birth on the EHR or paper chart before making an entry to ensure you have the correct record. If the medical assistant records in the wrong patient's record by mistake, information such as a procedure that was performed on a patient may be excluded from the correct patient's record. As previously stated, from a legal standpoint, a procedure not documented was not performed. 2. Document information accurately in a logical order 3. Spell correctly 4. Document procedures 5. Write legibly Why is it important to document and sign all necessary instructions? - correct answersThis protects the physician legally in the event that the patient fails to follow the instructions and causes further harm or damage to a body part. What is data? - correct answersgeneral term used to describe the raw, unorganized facts presented to the computer for processing. Patients' names, addresses, and telephone numbers are examples of data What is input? - correct answersThe input of data is the transfer of data to the computer for processing. What is processing? - correct answersThe processing of data is the handling and arranging of the electronic data by the computer according to a program; in other words, the data undergo some type of manipulation or change to produce useful information. What is output? - correct answersthe transfer of usable information back to the user. Because the computer works with an electronic code, an output device must be used to communicate with the user. What is an output device? Give an example. - correct answersMonitor and printer What is system software? - correct answersmade up of a group of special programs that control or maintain the operations of a computer. What is an operating system? Give an example. - correct answersAn operating system is the most important type of system. An example of an operating system frequently used in the medical office is Windows (Microsoft Corporation). What is a spreadsheet? - correct answersan electronic ledger designed to perform mathematic calculations quickly. The data in EHR systems can link to what large pool of information? - correct answersadd new information, modify existing information, and delete unneeded information Many physicians use voice recognition software to do what? - correct answersdictate progress notes and reports. To prevent overheating of the main computer unit, what care should be taken? - correct answersthe main unit should not be placed near a window or other areas that receive direct sunlight. In addition, to prevent overheating, the ventilation slots on the main unit should not be obstructed. How should the monitor be positioned to prevent back and neck tension? - correct answersThe monitor should be placed directly in front of the user and at an arm's length distance when sitting back in a chair. eve muscles must work harder to tocus on near oblects. How can eve strain be avoided while working on the computer? - correct answersthe top of the monitor is approximately 2 to 3 inches above eye level. Also, occasionally focus your eyes on a distant object (more than 20 feet away) to prevent eyestrain What is a privacy filter? - correct answersreduce glare as well as increase privacy of screen information by blurring or blacking out the screen image to anyone who is not directly in front of it. What type of material should be used to clean an LCD monitor? - correct answersUse a lint-free cloth. Do not use paper towels or tissues because they can scratch the screen. If the dry cloth does not remove all soil, do not press harder because the screen can be damaged. If necessary, use distilled water on a soft cloth or commercial wipes or cleaners for LCD screens. Do not use cleaners that contain chemicals such as ethyl alcohol or acetone, because these can discolor the screen Grime can be removed from a keyboard using what? - correct answers cleaned with an antiseptic wipe or a slightly damp, lint-free cloth What is one type of an optical disc? - correct answers a compact disc (CD), which can hold about 650 MB of data. Application software or backup application software may come on a CD. What is a USB flash drive? - correct answersa portable storage device that consists of a small circuit board in a plastic case What is the audit trail used for? - correct answers Privacy of the pt What software application can be used to access the World Wide Web? - correct answers Chrome, Firefox, Safari What does the messaging system within the EHR allow? - correct answers allows secure communications among health care providers and gives the ability to link directly to clinical and laboratory data regarding patients. What is a patient portal? - correct answersonline application that allows patients to interact with and communicate with their health care providers. In addition to access to laboratory reports and health education resources, there is often a secure e-mail system allowing patients to communicate directly with health care providers and other staff members by secure e-mail What is e-prescribing? - correct answers transmission of prescriptions directly to pharmacies electronically What does an effective password consist of? - correct answers include random series of digits, letters, and symbols rather than English words, telephone numbers, or other combinations that have meaning What is antivirus software also known as? - correct answers a utility program What is a computer virus? - correct answers refers to software designed to penetrate a computer or network without consent. A computer virus can access information and/or cause damage. What is a firewall? - correct answers a system that protects a computer network from unauthorized access by users on its own network or another network, such as the internet What is a backup? - correct answers A duplicate copy of a program or data kept for reference in case the original is damaged, lost, or destroyed. What is used for disposing of confidential documents? - correct answers Shred papers