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