TEST BANK FOR CLINICAL PROCEDURES FOR MEDICAL ASSISTANTS 10TH EDITION BY BONEWIT-WEST
Complete
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 betterNcontrol
URSIN GTthe
over B.C OMand disclosure of their health
use
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.
NURSINGTB.COM
, TEST BANK FOR CLINICAL PROCEDURES FOR MEDICAL ASSISTANTS 10TH EDITION BY BONEWIT-WEST
Complete
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 laboratoryNtests
URStoINbeGperformed
TB.COM 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
NURSINGTB.COM
, TEST BANK FOR CLINICAL PROCEDURES FOR MEDICAL ASSISTANTS 10TH EDITION BY BONEWIT-WEST
Complete
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 URSINGTB.COM
be quickly retrieved.
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
NURSINGTB.COM
, TEST BANK FOR CLINICAL PROCEDURES FOR MEDICAL ASSISTANTS 10TH EDITION BY BONEWIT-WEST
Complete
17. What is the name of a program that converts typed text into text that can be manipulated by
the computer (once it has been scanned into the computer)?
a. POMR
b. OCR
c. Word processing program
d. Practice management program
ANS: B REF: p. 6| CAAHEP Competency (2015): VI.12
OBJ: 4
18. All of the following assist in the collection of data for a health history except
a. a quiet, comfortable room.
b. showing interest in the patient.
c. showing concern for the patient.
d. calling the patient “honey.”
ANS: D REF: p. 6| CAAHEP Competency (2015): V.3.
OBJ: 8
19. Which of the following can be used to enter a health history into an electronic medical record?
a. The patient completes a paper form and the medical assistant scans it into the
computer.
b. The medical assistant enters information into the computer while asking the patient
questions.
c. The patient completes a health history questionnaire on a computer.
d. All of the above
ANS: D REF: p. 6|NCAAHEP
URSINGCompetency
TB.COM(2015): IX.12
OBJ: 8
20. What is a health history?
a. A legal document required to perform certain procedures on a patient
b. Documentation of the results of the physical examination
c. A collection of subjective data about the patient
d. A narrative description and interpretation of a diagnostic procedure
ANS: C REF: p. 6| CAAHEP Competency (2015): V.10
OBJ: 6
21. The health history is taken
a. after the provider performs the physical examination.
b. after laboratory test results are reviewed.
c. before the provider performs the physical examination.
d. after the provider makes a diagnosis of the patient’s condition.
ANS: C REF: p. 6| CAAHEP Competency (2015): VI.4
OBJ: 6
22. What is the chief complaint?
a. The probable outcome of the patient’s condition
b. The symptom causing the patient the most trouble
c. A detailed description of the patient’s illness using medical terms
NURSINGTB.COM
Complete
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 betterNcontrol
URSIN GTthe
over B.C OMand disclosure of their health
use
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.
NURSINGTB.COM
, TEST BANK FOR CLINICAL PROCEDURES FOR MEDICAL ASSISTANTS 10TH EDITION BY BONEWIT-WEST
Complete
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 laboratoryNtests
URStoINbeGperformed
TB.COM 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
NURSINGTB.COM
, TEST BANK FOR CLINICAL PROCEDURES FOR MEDICAL ASSISTANTS 10TH EDITION BY BONEWIT-WEST
Complete
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 URSINGTB.COM
be quickly retrieved.
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
NURSINGTB.COM
, TEST BANK FOR CLINICAL PROCEDURES FOR MEDICAL ASSISTANTS 10TH EDITION BY BONEWIT-WEST
Complete
17. What is the name of a program that converts typed text into text that can be manipulated by
the computer (once it has been scanned into the computer)?
a. POMR
b. OCR
c. Word processing program
d. Practice management program
ANS: B REF: p. 6| CAAHEP Competency (2015): VI.12
OBJ: 4
18. All of the following assist in the collection of data for a health history except
a. a quiet, comfortable room.
b. showing interest in the patient.
c. showing concern for the patient.
d. calling the patient “honey.”
ANS: D REF: p. 6| CAAHEP Competency (2015): V.3.
OBJ: 8
19. Which of the following can be used to enter a health history into an electronic medical record?
a. The patient completes a paper form and the medical assistant scans it into the
computer.
b. The medical assistant enters information into the computer while asking the patient
questions.
c. The patient completes a health history questionnaire on a computer.
d. All of the above
ANS: D REF: p. 6|NCAAHEP
URSINGCompetency
TB.COM(2015): IX.12
OBJ: 8
20. What is a health history?
a. A legal document required to perform certain procedures on a patient
b. Documentation of the results of the physical examination
c. A collection of subjective data about the patient
d. A narrative description and interpretation of a diagnostic procedure
ANS: C REF: p. 6| CAAHEP Competency (2015): V.10
OBJ: 6
21. The health history is taken
a. after the provider performs the physical examination.
b. after laboratory test results are reviewed.
c. before the provider performs the physical examination.
d. after the provider makes a diagnosis of the patient’s condition.
ANS: C REF: p. 6| CAAHEP Competency (2015): VI.4
OBJ: 6
22. What is the chief complaint?
a. The probable outcome of the patient’s condition
b. The symptom causing the patient the most trouble
c. A detailed description of the patient’s illness using medical terms
NURSINGTB.COM
