Bonewit: Clinical Procedures for Medical Assistants, 8th Edition
Chapter 1: The Medical Record
Test Bank
CAAHEP Cognitive (Knowledge Base)
IV. Concepts of Effective Communication:
6. Differentiate between subjective and objective information
9. Discuss applications of electronic technology in effective communication
11. Define both medical terms and abbreviations related to all body systems
12. Organize technical information and summaries
V. Administrative Functions:
5. Identify systems for organizing medical records
6. Describe various types of content maintained in a patient’s medical record
8. Identify both equipment and supplies needed for filing medical recrods
11. Discuss principles of using Electronic Medical Record (EMR)
12. Identify types of records common to the health care setting
IX. Legal Implications:
1. Explore issue of confidentiality as it applies to the medical assistant
3. Describe the implications of HIPAA for the medical assistant in various medical
settings
13. Discuss all levels of governmental legislation and regulation as they apply to
medical assisting practice, including FDA and DEA regulations
ABHES Content Competencies
3. Medical Terminology:
a. Basic structure of medical words
b. Word element combinations
d. Medical abbreviations
4. Medical Law and Ethics:
a. Documentation
b. Federal and state guidelines
, c. Established policies
f. Health laws and regulations
6. Pharmacology:
g. Records for medications and immunizations
8. Medical Office Business Procedures/ Management:
b. Medical records
y. Effective communication
9. Medical Office Clinical Procedures:
a. Patient history
, MULTIPLE CHOICE
Directions: Choose the best answer.
Each question is worth 1.5 points.
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
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
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
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
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
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
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
8. A narrative report of an opinion about a patient’s condition by a practitioner other than
the attending physician is known as a
a. Correspondence report
b. Discharge summary report
c. Consultation report
d. Health history report
ANS: C
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
10. A report of the analysis of body specimens is known as a
Chapter 1: The Medical Record
Test Bank
CAAHEP Cognitive (Knowledge Base)
IV. Concepts of Effective Communication:
6. Differentiate between subjective and objective information
9. Discuss applications of electronic technology in effective communication
11. Define both medical terms and abbreviations related to all body systems
12. Organize technical information and summaries
V. Administrative Functions:
5. Identify systems for organizing medical records
6. Describe various types of content maintained in a patient’s medical record
8. Identify both equipment and supplies needed for filing medical recrods
11. Discuss principles of using Electronic Medical Record (EMR)
12. Identify types of records common to the health care setting
IX. Legal Implications:
1. Explore issue of confidentiality as it applies to the medical assistant
3. Describe the implications of HIPAA for the medical assistant in various medical
settings
13. Discuss all levels of governmental legislation and regulation as they apply to
medical assisting practice, including FDA and DEA regulations
ABHES Content Competencies
3. Medical Terminology:
a. Basic structure of medical words
b. Word element combinations
d. Medical abbreviations
4. Medical Law and Ethics:
a. Documentation
b. Federal and state guidelines
, c. Established policies
f. Health laws and regulations
6. Pharmacology:
g. Records for medications and immunizations
8. Medical Office Business Procedures/ Management:
b. Medical records
y. Effective communication
9. Medical Office Clinical Procedures:
a. Patient history
, MULTIPLE CHOICE
Directions: Choose the best answer.
Each question is worth 1.5 points.
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
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
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
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
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
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
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
8. A narrative report of an opinion about a patient’s condition by a practitioner other than
the attending physician is known as a
a. Correspondence report
b. Discharge summary report
c. Consultation report
d. Health history report
ANS: C
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
10. A report of the analysis of body specimens is known as a
