Test Bank For Clinical Procedures for Medical Assistants 11th Edition by Kathy Bonewit-West, ISBN 978-0323758581, Chapter 1-23

,Chapter 01: The Medical Record
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Bonewit-West: Clinical Procedures for Medical Assistants, 11th Edition
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MULTIPLECHOICE

1. Whatrinformationrisrcontainedrinrthermedical rrecord?
a. Healthrhistoryreport
b. Resultsrofrtherphysical rexamination
c. Laboratoryrreports
d. Progressrnotes
e. Allrof rtherabove

ANS: r r r E REF: rpp. r2-3| rCAAHEP rCompetency r(2015): rVI.4
rOBJ: r 2




2. Whichrof rtherfollowingis rnotrarfunction rofrthermedical rrecord?
a. Torproviderinformation rforrmakingrdecisionsrregardingrthe rpatient’srcare
b. Tordocument rtherpatient’srprogress
c. Torserve rasrarlegal rdocument
d. Torsharerinformation rbetween rmembersrofrtherpatient’srfamily

ANS: r r r D REF: rp. r2| rCAAHEP rCompetency r(2015): rVI.4
rOBJ: r 1




3. Therpurposerofrthe rHIPAArPrivacyrRule risrto
a. reducerexposurerofrpatientsrtorbloodbornerpathogens.
b. provide rpatients rwith rbetterNcU
onRtS
roI
lN
ovGeT
fr tB
h.
e ruCsO
f eMand rdisclosure rof rtheir rhealth
information.
r

c. preventrtherpatient’srrecordsrfrom rbeingrcopied.
d. encouragertherpatient rtorbecome rmorerinvolvedrinrpreventive rhealthcare.

ANS: r r r B REF: rp. r4 r| rCAAHEP rCompetency r(2015): rIX.3
rOBJ: r 2




4. Allrofrthe rfollowingrarercharacteristicsrofrthe rNotice rofrPrivacyrPractices rexcept:
a. Wasrdevelopedrbythe rAmerican rMedical rAssociation
b. Mustrexplainrhow rarpatient’srhealth rinformation rwillrberusedrand rprotected rbyrthe
medical roffice
r

c. Mustrberprovidedrtoreach rpatient
d. Mustrobtainrarsignedracknowledgment rfromrtherpatientrthatrhe/sherhasrreceivedran
NPP
r



ANS: r r r A REF: rp. r4| rCAAHEP rCompetency r(2015): rIX.3
rOBJ: r 2




5. Healthrinformationrinranyformrthatrcontainsrpatientridentifiablerinformationrisrknownras
a. PHI.
b. NPP.
c. OSHA.
d. HIPAA.

, ANS: r r r A REF: rp. r4| rCAAHEP rCompetency r(2015): rIX.3
rOBJ: r 2




6. In rwhich rofrtherfollowing rsituationsrdoesrHIPAA rnotrrequirerwrittenrconsent rforrtheuseror
disclosurerof rprotected rhealth rinformation?
r

a. Patientrreferralrtorarspecialist
b. Emergencyrcare rprovided ratrarhospital
c. Determinationrofreligibilityrforinsurancerbenefits
d. Trainingrofrhealth rcarerstudents
e. Allrof rtherabove
ANS: r r r E REF: rp. r4| rCAAHEP rCompetency r(2015): rIX.3
rOBJ: r 2




7. Whichrofrthe rfollowingis rnot ranrexamplerofrarmedical roffice rclinical rdocument?
a. Patientregistration rrecord
b. Physicalrexaminationrreport
c. Medicationrrecord
d. Healthrhistoryreport

ANS: r r r A REF: rpp. r2-3| rCAAHEP rCompetency r(2015): rVI.4
rOBJ: r 2




8. Whichrofrthe rfollowingis rnotrarcharacteristic rof rarlaboratory rreport?
a. It rrelays rresultsrofrlaboratoryrtestsrtortherprovider
b. It rconsistsrof ra rreport rofrtheranalysisrorrexamination rofrbodyspecimens
c. It rassistsrinrdiagnosingrandtreatingrdisease
d. It ris ra rrequest rforrl aboratoryNtU
esRtsStI
oNbeGpTeB
rf.
orCmOeM
d rby ran routside rlaboratory
ANS: r r r D REF: rpp. r2-3| rCAAHEP rCompetency r(2015): rVI.4
rOBJ: r 2




9. Whichrofrtherfollowingrisranrexamplerofrardiagnostic rprocedure rreport?
a. Electrocardiogramrreport
b. Physical rtherapyreport
c. Urinalysisreport
d. Pathologyreport

ANS: r r r A REF: rpp. r2-3| rCAAHEP rCompetency r(2015): rVI.4
rOBJ: r 2




10. Whatrisrthe rnamerofrthertyperofrreport rthatrdocumentsrtherassessmentsrand rtreatments
designed rto rrestore ra rpatient’s rabilityto rfunction?
r

a. Consultationrreport
b. Diagnosticrprocedure rreport
c. Pathologyreport
d. Therapeuticrservicerreport
ANS: r r r D REF: rpp. r2-3| rCAAHEP rCompetency r(2015): rVI.4
rOBJ: r 2




11. Which rofrthe rfollowingis rnot ranrexampleof rarhospital rreport?
a. Operativerreport

, b. Cytologyrreport
c. Dischargersummaryrreport
d. Emergencydepartment rreport

ANS: r r r B REF: rpp. r2-3| rCAAHEP rCompetency r(2015): rVI.4
rOBJ: r 2




12. Whichrofrthe rfollowingis ran rexample rof rarconsent rdocument?
a. Patientregistration rrecord
b. NoticerofrPrivacyrPractices rform
c. Release rofmedical rinformation rform
d. Patientinstruction rsheet

ANS: r r r C REF: rpp. r2-3| rCAAHEP rCompetency r(2015): rVI.4
rOBJ: r 2




13. Whichrofrthe rfollowingcan rberperformedrbyran relectronic rmedical rrecordrsoftware rprogram?
a. Creationro fa rmedical rrecord
b. Storagerofrarmedical rrecord
c. Editingofra rmedical rrecord
d. Retrieval rofrarmedical rrecord
e. Allrof rtherabove
ANS: r r r E REF: rp. r3| rCAAHEP rCompetency r(2015): rV.8
rOBJ: r 3



14. Allrofrtherfollowingrareradvantages rofranrelectronicrmedical rrecord r(EMR) rexcept
a. anrEMR rdoesrnot rhaveto rberfiled.
b. documents rin an rEMR rcanrN beUqRuS
icI
klNyGreTtrBie.vC
edO.M
c. morerthan ronerperson rcan rviewranrEMR rat rthersamertime.
d. EMRsarerexemptrfrom rtherHIPAArregulations.
ANS: r r r D REF: rpp. r3, r6|rCAAHEP rCompetencyr(2015):rVI.12
rOBJ: r 5




15. Whichrofrthe rfollowingare rusedto renter rdata rinto ranrelectronic rmedical rrecord?
a. Free-textentry
b. Drop-downrmenus
c. Radiorbuttons
d. Allrof rtherabove
ANS: r r r D REF: rp. r11| rCAAHEP rCompetency r(2015): rV.8
rOBJ: r 8




16. Howare rpaper rdocuments renteredinto ra rpatient’s relectronic rmedical rrecord?
a. Byscanning rthem rintothe rcomputer
b. Byretypingrthem ron rthe rcomputer
c. Byphotocopying rthem
d. Bytransmittingrthem rthroughra rmodem
ANS: r r r A REF: rp. r11| rCAAHEP rCompetency r(2015): rVI.4
rOBJ: r 8