ASSISTANTS 11TH EDITION/ALL CHAPTERS 1-
23/COMPLETE GUIDE 2024-2025
,CH 01: The Clinical Record
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Bonewit-West: Clinical Procedures for Clinical Assistants, 11th Editiontc tc tc tc tc tc tc
MULTIPLE CHOICE tc
1. Which of the following is not a function of the clinical record?
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a. To provide information for making decisions regarding the patient’s care
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b. To document the patient’s progress
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c. To serve as a legal document tc tc tc tc tc
d. To share information between members of the patient’s family
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ACCURATE CHOICE:D REF: page. 2| CAAHEP Competency (2015): tc tc tc tc tc tc tc tc
VI.4OBJ: 1 tc tc
2. What information is contained in the clinical record?
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a. Health history report tc tc
b. Results of the physical examination tc tc tc tc
c. Laboratory reports tc
d. Progress notes tc
e. All of the above tc tc tc
ACCURATE CHOICE:E REF: page. 2- tc tc tc tc
3| CAAHEP Competency (2015): VI.4OBJ: 2
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3. The purpose of the HIPAA Privacy Rule is to
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a. reduce exposure of patients to bloodborne pathogens. tc tc tc tc tc tc
b. provide patients with b e t t e rNcUo nRt S
r oIl N
ovGeT
r tBhe.C
usOe Mand disclosure of their he
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alth information. tc
c. prevent the patient’s records from being copied. tc tc tc tc tc tc
d. encourage the patient to become more involved in preventive primary health care.tc tc tc tc tc tc tc tc tc tc tc
ACCURATE CHOICE: B REF: page. 4 | CAAHEP Competency (2015) tc tc tc tc tc tc tc tc tc
: IX.3OBJ: 2
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4. All of the following are characteristics of the Notice of Privacy Practices except:
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a. Was developed by the American Clinical Association
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b. Must explain how a patient’s health information will be used and protected by
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theclinical office tc tc
c. Must be provided to each patient tc tc tc tc tc
d. Must obtain a signed acknowledgment from the patient that he/she has receive
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d anNPP tc tc
ACCURATE CHOICE:A REF: page. 4| CAAHEP Competency (2015): tc tc tc tc tc tc tc tc
IX.3OBJ: 2 tc tc
5. Health information in any form that contains patient identifiable information is known as
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a. PHI.
b. NPAGE.
c. OSHA.
d. HIPAA.
, ACCURATE CHOICE:A REF: page. 4| CAAHEP Competency (2015):
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IX.3OBJ: 2 tc tc
6. In which of the following situations does HIPAA not require written consent for the use
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ordisclosure of protected health information?
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a. Patient referral to a specialist tc tc tc tc
b. Emergency care provided at a medical center tc tc tc tc tc tc
c. Determination of eligibility for insurance benefits tc tc tc tc tc
d. Training of primary health care students tc tc tc tc tc
e. All of the above tc tc tc
ACCURATE CHOICE:E REF: page. 4| CAAHEP Competency (2015):
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IX.3OBJ: 2 tc tc
7. Which of the following is not an example of a clinical office clinical document?
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a. Patient registration record tc tc
b. Physical examination report tc tc
c. Medication record tc
d. Health history report tc tc
ACCURATE CHOICE:A REF: page. 2- tc tc tc tc
3| CAAHEP Competency (2015): VI.4OBJ: 2
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8. Which of the following is not a characteristic of a laboratory report?
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a. It relays results of laboratory tests to the provider
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b. It consists of a report of the analysis or examination of body specimens
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c. It assists in diagnosing and treating sickness
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d. It is a request for labo rat oryNtUesRtsStIo N
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d by an outside laboratory
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ACCURATE CHOICE:D REF: page. 2- tc tc tc tc
3| CAAHEP Competency (2015): VI.4OBJ: 2
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9. Which of the following is an example of a diagnostic procedure report?
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a. Electrocardiogram report tc
b. Physical therapy report tc tc
c. Urinalysis report tc
d. Pathology report tc
ACCURATE CHOICE:A REF: page. 2- tc tc tc tc
3| CAAHEP Competency (2015): VI.4OBJ: 2
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10. What is the name of the type of report that documents the assessments and treatme
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ntsdesigned to restore a patient’s ability to function?
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a. Consultation report tc
b. Diagnostic procedure report tc tc
c. Pathology report tc
d. Therapeutic service report tc tc
ACCURATE CHOICE:D REF: page. 2- tc tc tc tc
3| CAAHEP Competency (2015): VI.4OBJ: 2
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11. Which of the following is not an example of a medical center report?
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a. Operative report tc
, b. Cytology report tc
c. Discharge summary report tc tc
d. Emergency department report tc tc
ACCURATE CHOICE:B tc
REF: page. 2-3| CAAHEP Competency (2015): VI.4 OBJ:
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12. Which of the following is an example of a consent document?
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a. Patient registration record tc tc
b. Notice of Privacy Practices form tc tc tc tc
c. Release of clinical information form tc tc tc tc
d. Patient instruction sheet tc tc
ACCURATE CHOICE:C REF: page. 2- tc tc tc tc
3| CAAHEP Competency (2015): VI.4OBJ: 2
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13. Which of the following can be performed by an electronic clinical record software program?
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a. Creation of a clinical record tc tc tc tc
b. Storage of a clinical record tc tc tc tc
c. Editing of a clinical record tc tc tc tc
d. Retrieval of a clinical record tc tc tc tc
e. All of the above tc tc tc
ACCURATE CHOICE:E REF: page. 3| CAAHEP Competency (2015): tc tc tc tc tc tc tc tc
V.8OBJ: 3 tc tc
14. All of the following are advantages of an electronic clinical record (EMR) except
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a. an EMR does not have to be filed.
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b. documents in an EMR can N beUqRuS
icIk N
lyGreTtrBie.vC
edO.M tc tc tc tc tc tc
c. more than one person can view an EMR at the same time.
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d. EMRs are exempt from the HIPAA regulations. tc tc tc tc tc tc
ACCURATE CHOICE:D REF: page. 3, 6| CAAHEP Competency (2015): VItc tc tc tc tc tc tc tc tc
.12OBJ: 5
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15. Which of the following are used to enter data into an electronic clinical record?
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a. Free-text entry tc
b. Drop-down menus tc
c. Radio buttons tc
d. All of the above tc tc tc
ACCURATE CHOICE:D REF: page. 11| CAAHEP Competency (2015): tc tc tc tc tc tc tc tc
V.8OBJ: 8 tc tc
16. How are paper documents entered into a patient’s electronic clinical record?
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a. By scanning them into the computer
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b. By retyping them on the computer
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c. By photocopying them tc tc
d. By transmitting them through a modem
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ACCURATE CHOICE:A REF: page. 11| CAAHEP Competency (2015): tc tc tc tc tc tc tc tc
VI.4OBJ: 8 tc tc