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Table of Contents
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Chapter 1: The Medical Record
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Chapter 2: Medical Asepsis and the OSHA Standard
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Chapter 3: Sterilization and Disinfection
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Chapter 4: Vital Signs
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Chapter 5: The Physical Examination,
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Chapter 6: Eye and Ear Assessment and Procedures
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Chapter 7: Physical Agents to Promote Tissue Healing
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Chapter 8: The Gynecologic Examination and Prenatal Care
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Chapter 9: The Pediatric Examination
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Chapter 10: Minor Office Surgery
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Chapter 11: Administration of Medication and Intravenous Therapy
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Chapter 12: Cardiopulmonary Procedures
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Chapter 13: Colon Procedures and Male Reproductive Health
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Chapter 14: Radiology and Diagnostic Imaging
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Chapter 15: Introduction to the Clinical Laboratory
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Chapter 16: Urinalysis
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Chapter 17: Phlebotomy
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Chapter 18: Hematology
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Chapter 19: Blood Chemistry and Immunology
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Chapter 20: Medical Microbiology
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Chapter 21: Nutrition - NEW
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Chapter 22: Emergency Preparedness - NEW
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Chapter 23: Emergency Medical Procedures and First Aid
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,Chapter 01: The Medical Record
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Bonewit-West: Clinical Procedures for Medical Assistants, 11th Edition
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MULTIPLE CHOICE f
1. Which of the following is not a function of the medical 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
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d. To share information between members of the patient’s family
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ANS: D f REF: p. 2| CAAHEP Competency (2015): VI.4 f f f f f f
OBJ: 1
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2. What information is contained in the medical record?
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a. Health history report f f
b. Results of the physical examination f f f f
c. Laboratory reports f
d. Progress notes f
e. All of the above f f f
ANS: E f REF: pp. 2-3| CAAHEP Competency (2015): VI.4f f f f f f
OBJ: 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.
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b. provide patients with better control over the use and disclosure of their health
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information.
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c. prevent the patient’s records from being copied. f f f f f f
d. encourage the patient to become more involved in preventive health care. f f f f f f f f f f
ANS: B f REF: p. 4 | CAAHEP Competency (2015): IX.3 f f f f f f f
OBJ: 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 Medical Association
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b. Must explain how a patient’s health information will be used and protected by the
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medical office
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c. Must be provided to each patient f f f f f
d. Must obtain a signed acknowledgment from the patient that he/she has received an
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NPP f
ANS: A f REF: p. 4| CAAHEP Competency (2015): IX.3 f f f f f f
OBJ: 2
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5. Health information in any form that contains patient identifiable information is known as
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a. PHI.
b. NPP.
c. OSHA.
d. HIPAA.
, ANS: A f REF: p. 4| CAAHEP Competency (2015): IX.3 f f f f f f
OBJ: 2
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6. In which of the following situations does HIPAA not require written consent for the use or
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fdisclosure of protected health information? f f f f
a. Patient referral to a specialist f f f f
b. Emergency care provided at a hospital f f f f f
c. Determination of eligibility for insurance benefits f f f f f
d. Training of health care students f f f f
e. All of the above f f f
ANS: E f REF: p. 4| CAAHEP Competency (2015): IX.3 f f f f f f
OBJ: 2
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7. Which of the following is not an example of a medical office clinical document?
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a. Patient registration record f f
b. Physical examination report f f
c. Medication record f
d. Health history report f f
ANS: A f REF: pp. 2-3| CAAHEP Competency (2015): VI.4f f f f f f
OBJ: 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 disease
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d. It is a request for laboratory tests performed by an outside laboratory
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ANS: D f REF: pp. 2-3| CAAHEP Competency (2015): VI.4f f f f f f
OBJ: 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 f
b. Physical therapy report f f
c. Urinalysis report f
d. Pathology report f
ANS: A f REF: pp. 2-3| CAAHEP Competency (2015): VI.4f f f f f f
OBJ: 2
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10. What is the name of the type of report that documents the assessments and treatments
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designed to restore a patient’s ability to function?
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a. Consultation report f
b. Diagnostic procedure report f f
c. Pathology report f
d. Therapeutic service report f f
ANS: D f REF: pp. 2-3| CAAHEP Competency (2015): VI.4f f f f f f
OBJ: 2
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11. Which of the following is not an example of a hospital report?
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a. Operative report f