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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 ff
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 f REF: p. 2| CAAHEP Competency (2015): VI.4 ff ff ff ff ff ff
OBJ: 1
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2. What information is contained in the medical record?
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a. Health history report ff ff
b. Results of the physical examination ff ff ff ff
c. Laboratory reports ff
d. Progress notes ff
e. All of the above ff ff ff
ANS: E f f REF: pp. 2-3| CAAHEP Competency (2015): VI.4
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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. ff ff ff ff ff ff
d. encourage the patient to become more involved in preventive health care. ff ff ff ff ff ff ff ff ff ff
ANS: B f f REF: p. 4 | CAAHEP Competency (2015): IX.3 ff ff ff ff ff ff ff
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 ff ff ff ff ff
d. Must obtain a signed acknowledgment from the patient that he/she has received an
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NPP ff
ANS: A f f REF: p. 4| CAAHEP Competency (2015): IX.3 ff ff ff ff ff ff
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 f REF: p. 4| CAAHEP Competency (2015): IX.3
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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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disclosure of protected health information?
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a. Patient referral to a specialist ff ff ff ff
b. Emergency care provided at a hospital ff ff ff ff ff
c. Determination of eligibility for insurance benefits ff ff ff ff ff
d. Training of health care students ff ff ff ff
e. All of the above ff ff ff
ANS: E f f REF: p. 4| CAAHEP Competency (2015): IX.3
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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 ff ff
b. Physical examination report ff ff
c. Medication record ff
d. Health history report ff ff
ANS: A f f REF: pp. 2-3| CAAHEP Competency (2015): VI.4
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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 f REF: pp. 2-3| CAAHEP Competency (2015): VI.4
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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 ff
b. Physical therapy report ff ff
c. Urinalysis report ff
d. Pathology report ff
ANS: A f f REF: pp. 2-3| CAAHEP Competency (2015): VI.4
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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 ff
b. Diagnostic procedure report ff ff
c. Pathology report ff
d. Therapeutic service report ff ff
ANS: D f f REF: pp. 2-3| CAAHEP Competency (2015): VI.4
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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 ff