Chapter 1: The Medical Record
Test Bank
MULTIPLE CHOICE
1. What information is contained in the medical record?
a. Health history
b. Results of the physical examination
c. Laboratory reports
d. Progress notes
e. All of the above
ANS: E TOP: CAAHEP Cognitive Competency Met: V. 6
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 TOP: CAAHEP Cognitive Competency Met: V. 6
3. The purpose of HIPAA is to
a. reduce exposure of patients to bloodborne pathogens.
b. provide patients with more control over the use and disclosure of their health
information.
c. prevent the patient’s records from being copied.
d. encourage the patient to become more involved in preventive health care.
ANS: B TOP: CAAHEP Cognitive Competency Met: IX. 3
4. The patient registration record consists of
a. demographic and billing information.
b. medication instructions given to the patient.
c. the results of the physical examination.
d. a list of problems associated with the patient’s illness.
e. all of the above.
ANS: A TOP: CAAHEP Cognitive Competency Met: V. 6
5. All of the following are included in the patient registration record except
a. date of birth.
b. allergies.
c. employer.
d. patient’s insurance company.
ANS: B TOP: CAAHEP Cognitive Competency Met: V. 6
6. Which of the following provides subjective data about a patient to assist the physician in
arriving at a diagnosis?
a. Laboratory tests
, b. Physical examination
c. Health history
d. Diagnostic tests
ANS: C TOP: CAAHEP Cognitive Competency Met: IV. 6
7. Which of the following is not included on a medication record for medication administered at
the office?
a. Name of the medication
b. Route of administration
c. Dosage administered
d. Number of refills
ANS: D TOP: CAAHEP Cognitive Competency Met: V. 6
8. A narrative report of an opinion about a patient’s condition by a practitioner other than the
attending physician is known as a _____ report.
a. correspondence
b. discharge summary
c. consultation
d. health history
ANS: C TOP: CAAHEP Cognitive Competency Met: V. 12
9. Which of the following services may be provided through home health care?
a. IV therapy
b. Respiratory care
c. Rehabilitation
d. Maternal-child care
e. All of the above
ANS: E TOP: CAAHEP Cognitive Competency Met: I. 9
10. A report of the analysis of body specimens is known as a _____ report.
a. therapeutic
b. diagnostic
c. laboratory
d. progress
ANS: C TOP: CAAHEP Cognitive Competency Met: V. 12
11. All of the following are examples of diagnostic reports except _____ report.
a. urinalysis
b. spirometry
c. colonoscopy
d. radiology
ANS: A TOP: CAAHEP Cognitive Competency Met: V. 12
12. All of the following are examples of physical therapy except
a. electrical stimulation.
b. hydrotherapy.
c. therapeutic exercise.
, d. breathing treatments.
ANS: D
CAAHEP Cognitive Competency Met: I. 9
13. Which of the following helps a patient with a disability learn new skills to perform the
activities of daily living?
a. Speech therapy
b. Occupational therapy
c. Physical therapy
d. Dietitian
ANS: B TOP: CAAHEP Cognitive Competency Met: IV. 11
14. What term is used to describe a patient who has been admitted to the hospital for at least one
overnight stay?
a. Outpatient
b. Ambulatory patient
c. Guest
d. Inpatient
ANS: D TOP: CAAHEP Cognitive Competency Met: IV. 11
15. Conclusions drawn from an interpretation of data are known as
a. medical impressions.
b. prognosis.
c. symptoms.
d. charting.
ANS: A TOP: CAAHEP Cognitive Competency Met: IV. 11
16. All of the following are included in an operative report except
a. the name of the surgical procedure.
b. description of the procedure used during surgery.
c. prognosis.
d. postoperative diagnosis.
ANS: C TOP: CAAHEP Cognitive Competency Met: V. 12
17. Which of the following reports consists of an account of the significant events of a patient’s
hospitalization?
a. Emergency department report
b. Pathology report
c. History and physical report
d. Discharge summary report
ANS: D TOP: CAAHEP Cognitive Competency Met: V. 12
18. Which of the following reports consists of a macroscopic and microscopic description of
tissue removed during surgery?
a. Laboratory report
b. Pathology report
c. Diagnostic imaging report
, d. Operative report
ANS: B TOP: CAAHEP Cognitive Competency Met: V. 12
19. A copy of the patient’s emergency department report is sent to the
a. patient’s insurance company.
b. patient.
c. patient’s family physician.
d. laboratory.
ANS: C TOP: CAAHEP Cognitive Competency Met: I. 9
20. A consent to treatment form is required for
a. tuberculin skin testing.
b. sebaceous cyst removal.
c. ear irrigation.
d. blood pressure measurement.
ANS: B TOP: CAAHEP Cognitive Competency Met: V. 12
21. Which of the following must be included in informed consent?
a. An explanation of risks involved with the procedure
b. Any alternative treatments or procedures available
c. The prognosis
d. The purpose of the recommended procedure
e. All of the above
ANS: E TOP: CAAHEP Cognitive Competency Met: IX. 13
22. When a medical assistant witnesses a patient’s signature, it means that he or she verified
a. the patient’s identity and watched the patient sign the form.
b. that the information on the form is correct.
c. that the patient is aware of the risks involved with the procedure to be performed.
d. that the physician discussed informed consent with the patient.
ANS: A TOP: CAAHEP Cognitive Competency Met: IX. 13
23. Which of the following situations requires the completion of a release of medical information
form?
a. When a patient transfers records to a new physician
b. To bill the patient’s insurance company
c. To send the patient’s records to a consulting physician
d. To determine the patient’s eligibility for insurance benefits
ANS: A TOP: CAAHEP Cognitive Competency Met: IX. 13
24. All of the following are included on a release of medical information form except
a. the specific information to be released.
b. the need for the information.
c. the patient’s signature.
d. the expiration date of the release form.
e. medications being taken by the patient.
Test Bank
MULTIPLE CHOICE
1. What information is contained in the medical record?
a. Health history
b. Results of the physical examination
c. Laboratory reports
d. Progress notes
e. All of the above
ANS: E TOP: CAAHEP Cognitive Competency Met: V. 6
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 TOP: CAAHEP Cognitive Competency Met: V. 6
3. The purpose of HIPAA is to
a. reduce exposure of patients to bloodborne pathogens.
b. provide patients with more control over the use and disclosure of their health
information.
c. prevent the patient’s records from being copied.
d. encourage the patient to become more involved in preventive health care.
ANS: B TOP: CAAHEP Cognitive Competency Met: IX. 3
4. The patient registration record consists of
a. demographic and billing information.
b. medication instructions given to the patient.
c. the results of the physical examination.
d. a list of problems associated with the patient’s illness.
e. all of the above.
ANS: A TOP: CAAHEP Cognitive Competency Met: V. 6
5. All of the following are included in the patient registration record except
a. date of birth.
b. allergies.
c. employer.
d. patient’s insurance company.
ANS: B TOP: CAAHEP Cognitive Competency Met: V. 6
6. Which of the following provides subjective data about a patient to assist the physician in
arriving at a diagnosis?
a. Laboratory tests
, b. Physical examination
c. Health history
d. Diagnostic tests
ANS: C TOP: CAAHEP Cognitive Competency Met: IV. 6
7. Which of the following is not included on a medication record for medication administered at
the office?
a. Name of the medication
b. Route of administration
c. Dosage administered
d. Number of refills
ANS: D TOP: CAAHEP Cognitive Competency Met: V. 6
8. A narrative report of an opinion about a patient’s condition by a practitioner other than the
attending physician is known as a _____ report.
a. correspondence
b. discharge summary
c. consultation
d. health history
ANS: C TOP: CAAHEP Cognitive Competency Met: V. 12
9. Which of the following services may be provided through home health care?
a. IV therapy
b. Respiratory care
c. Rehabilitation
d. Maternal-child care
e. All of the above
ANS: E TOP: CAAHEP Cognitive Competency Met: I. 9
10. A report of the analysis of body specimens is known as a _____ report.
a. therapeutic
b. diagnostic
c. laboratory
d. progress
ANS: C TOP: CAAHEP Cognitive Competency Met: V. 12
11. All of the following are examples of diagnostic reports except _____ report.
a. urinalysis
b. spirometry
c. colonoscopy
d. radiology
ANS: A TOP: CAAHEP Cognitive Competency Met: V. 12
12. All of the following are examples of physical therapy except
a. electrical stimulation.
b. hydrotherapy.
c. therapeutic exercise.
, d. breathing treatments.
ANS: D
CAAHEP Cognitive Competency Met: I. 9
13. Which of the following helps a patient with a disability learn new skills to perform the
activities of daily living?
a. Speech therapy
b. Occupational therapy
c. Physical therapy
d. Dietitian
ANS: B TOP: CAAHEP Cognitive Competency Met: IV. 11
14. What term is used to describe a patient who has been admitted to the hospital for at least one
overnight stay?
a. Outpatient
b. Ambulatory patient
c. Guest
d. Inpatient
ANS: D TOP: CAAHEP Cognitive Competency Met: IV. 11
15. Conclusions drawn from an interpretation of data are known as
a. medical impressions.
b. prognosis.
c. symptoms.
d. charting.
ANS: A TOP: CAAHEP Cognitive Competency Met: IV. 11
16. All of the following are included in an operative report except
a. the name of the surgical procedure.
b. description of the procedure used during surgery.
c. prognosis.
d. postoperative diagnosis.
ANS: C TOP: CAAHEP Cognitive Competency Met: V. 12
17. Which of the following reports consists of an account of the significant events of a patient’s
hospitalization?
a. Emergency department report
b. Pathology report
c. History and physical report
d. Discharge summary report
ANS: D TOP: CAAHEP Cognitive Competency Met: V. 12
18. Which of the following reports consists of a macroscopic and microscopic description of
tissue removed during surgery?
a. Laboratory report
b. Pathology report
c. Diagnostic imaging report
, d. Operative report
ANS: B TOP: CAAHEP Cognitive Competency Met: V. 12
19. A copy of the patient’s emergency department report is sent to the
a. patient’s insurance company.
b. patient.
c. patient’s family physician.
d. laboratory.
ANS: C TOP: CAAHEP Cognitive Competency Met: I. 9
20. A consent to treatment form is required for
a. tuberculin skin testing.
b. sebaceous cyst removal.
c. ear irrigation.
d. blood pressure measurement.
ANS: B TOP: CAAHEP Cognitive Competency Met: V. 12
21. Which of the following must be included in informed consent?
a. An explanation of risks involved with the procedure
b. Any alternative treatments or procedures available
c. The prognosis
d. The purpose of the recommended procedure
e. All of the above
ANS: E TOP: CAAHEP Cognitive Competency Met: IX. 13
22. When a medical assistant witnesses a patient’s signature, it means that he or she verified
a. the patient’s identity and watched the patient sign the form.
b. that the information on the form is correct.
c. that the patient is aware of the risks involved with the procedure to be performed.
d. that the physician discussed informed consent with the patient.
ANS: A TOP: CAAHEP Cognitive Competency Met: IX. 13
23. Which of the following situations requires the completion of a release of medical information
form?
a. When a patient transfers records to a new physician
b. To bill the patient’s insurance company
c. To send the patient’s records to a consulting physician
d. To determine the patient’s eligibility for insurance benefits
ANS: A TOP: CAAHEP Cognitive Competency Met: IX. 13
24. All of the following are included on a release of medical information form except
a. the specific information to be released.
b. the need for the information.
c. the patient’s signature.
d. the expiration date of the release form.
e. medications being taken by the patient.
