CPT Practice Test Questions and
Answers | Latest Version | 2025/2026 |
Correct & Verified
How should a medical assistant document patient allergies?
✔✔Include the substance, reaction type, and severity
What is the purpose of documenting patient vital signs?
✔✔To establish baseline health status and monitor changes over time
Why must a medical assistant document patient education provided during a visit?
✔✔It supports patient understanding and compliance and justifies services
How should repeated procedures during a visit be documented?
✔✔Clearly note each occurrence and any differences in technique or outcome
Why is accurate documentation important for insurance purposes?
✔✔It ensures proper reimbursement and prevents claim denials
1
,What should be included when documenting a patient’s medical history?
✔✔Past illnesses, surgeries, medications, allergies, and family history
Why is it important to document the patient’s response to treatment?
✔✔To track effectiveness and inform future care decisions
How should a medical assistant document telehealth visits?
✔✔Include method, patient consent, and details of the services provided
Why is it necessary to document informed consent for procedures?
✔✔It protects patient rights and provides legal protection for the provider
What should be recorded if a procedure is partially completed?
✔✔The reason for incompletion and any alternative actions taken
Why is documentation of patient symptoms critical?
✔✔It guides diagnosis and treatment decisions
2
,How should a provider document abnormal lab results?
✔✔Include the value, reference range, and provider interpretation or plan
Why must follow-up instructions be documented?
✔✔To ensure patient compliance and continuity of care
How should a medical assistant document medication administration?
✔✔Include the medication, dose, route, time, and any reactions
Why is it important to document patient refusals of care?
✔✔To provide a legal record and inform future treatment
What should be documented if a patient experiences an adverse reaction?
✔✔Type of reaction, intervention, and outcome
Why is documenting risk factors important in a patient’s chart?
✔✔It informs preventive care and treatment planning
3
, How should communication with insurance companies be documented?
✔✔Include date, contact person, purpose, and outcome
Why should a provider document diagnostic reasoning?
✔✔It supports clinical decision-making and reimbursement justification
How should patient complaints be documented?
✔✔Clearly describe the complaint, duration, and any related findings
Why is it important to document procedures performed by other providers?
✔✔To maintain a complete record of care and coordinate treatment
What should be recorded when a procedure is performed on multiple body parts?
✔✔Specify each site and any differences in technique or outcome
How should patient follow-up appointments be documented?
✔✔Include date, time, purpose, and responsible provider
4
Answers | Latest Version | 2025/2026 |
Correct & Verified
How should a medical assistant document patient allergies?
✔✔Include the substance, reaction type, and severity
What is the purpose of documenting patient vital signs?
✔✔To establish baseline health status and monitor changes over time
Why must a medical assistant document patient education provided during a visit?
✔✔It supports patient understanding and compliance and justifies services
How should repeated procedures during a visit be documented?
✔✔Clearly note each occurrence and any differences in technique or outcome
Why is accurate documentation important for insurance purposes?
✔✔It ensures proper reimbursement and prevents claim denials
1
,What should be included when documenting a patient’s medical history?
✔✔Past illnesses, surgeries, medications, allergies, and family history
Why is it important to document the patient’s response to treatment?
✔✔To track effectiveness and inform future care decisions
How should a medical assistant document telehealth visits?
✔✔Include method, patient consent, and details of the services provided
Why is it necessary to document informed consent for procedures?
✔✔It protects patient rights and provides legal protection for the provider
What should be recorded if a procedure is partially completed?
✔✔The reason for incompletion and any alternative actions taken
Why is documentation of patient symptoms critical?
✔✔It guides diagnosis and treatment decisions
2
,How should a provider document abnormal lab results?
✔✔Include the value, reference range, and provider interpretation or plan
Why must follow-up instructions be documented?
✔✔To ensure patient compliance and continuity of care
How should a medical assistant document medication administration?
✔✔Include the medication, dose, route, time, and any reactions
Why is it important to document patient refusals of care?
✔✔To provide a legal record and inform future treatment
What should be documented if a patient experiences an adverse reaction?
✔✔Type of reaction, intervention, and outcome
Why is documenting risk factors important in a patient’s chart?
✔✔It informs preventive care and treatment planning
3
, How should communication with insurance companies be documented?
✔✔Include date, contact person, purpose, and outcome
Why should a provider document diagnostic reasoning?
✔✔It supports clinical decision-making and reimbursement justification
How should patient complaints be documented?
✔✔Clearly describe the complaint, duration, and any related findings
Why is it important to document procedures performed by other providers?
✔✔To maintain a complete record of care and coordinate treatment
What should be recorded when a procedure is performed on multiple body parts?
✔✔Specify each site and any differences in technique or outcome
How should patient follow-up appointments be documented?
✔✔Include date, time, purpose, and responsible provider
4
