MEDICAL 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 Edition
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MULTIPLE CHOICE P
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
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d. To share information between members of the patient’s family
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2. What information is contained in the clinical record?
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a. Health history report P P
b. Results of the physical examination P P P P
c. Laboratory reports P
d. Progress notes P
e. All of the above P P P
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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 be t t e rNcUo nRtS
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e Mand disclosure oftheir health P P P P P P P P P P P P P
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c. prevent the patient’s records from being copied. P P P P P P
d. encourage the patient to become more involved in preventive primary health care.
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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
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c. Must be provided to each patient P P P P P
d. Must obtain a signed acknowledgment from the patient that he/she has received an
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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. NPAGE.
c. OSHA.
d. HIPAA.
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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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disclosure of protected health information?
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a. Patient referral to a specialist P P P P
b. Emergency care provided at a medical center P P P P P P
c. Determination of eligibility for insurance benefits P P P P P
d. Training of primary health care students P P P P P
e. All of the above P P P
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7. Which of the following is not an example of a clinical office clinical document?
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a. Patient registration record P P
b. Physical examination report P P
c. Medication record P
d. Health history report P P
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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 ratoryNtUesRtsStI
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d by an outside laboratory
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9. Which of the following is an example of a diagnostic procedure report?
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a. Electrocardiogram report P
b. Physical therapy report P P
c. Urinalysis report P
d. Pathology report P
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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 P
b. Diagnostic procedure report P P
c. Pathology report P
d. Therapeutic service report P P
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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 P
, b. Cytology report P
c. Discharge summary report P P
d. Emergency department report P P
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12. Which of the following is an example of a consent document?
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a. Patient registration record P P
b. Notice of Privacy Practices form P P P P
c. Release of clinical information form P P P P
d. Patient instruction sheet P P
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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 P P P P
b. Storage of a clinical record P P P P
c. Editing of a clinical record P P P P
d. Retrieval of a clinical record P P P P
e. All of the above P P P
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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
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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.
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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 P
b. Drop-down menus P
c. Radio buttons P
d. All of the above P P P
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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
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d. By transmitting them through a modem
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