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TEST BANK FOR Clinical Procedures for Medical Assistants 10th Edition
by Kathy Bonewit-West




Chapter 01: The Medical Record
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MULTIPLE CHOICE

1. What information is contained in the medical record?
a. Health history report
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b. Results of the physical examination
c. Laboratory reports
d. Progress notes
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e. All of the above

ANS: E REF: pp. 2-3| CAAHEP Competency (2015): VI.4
OBJ: 2


2. 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


3. The purpose of the HIPAA Privacy Rule is to
a. reduce exposure of patients to bloodborne pathogens.
b. provide patients with betterNcU
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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.
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, 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
ST
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 laboratoryNtU
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d by an outside laboratory
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ANS: D REF: pp. 2-3| CAAHEP Competency (2015): VI.4
OBJ: 2
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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
ST
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
IC
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