MAST 1060 - Final Exam Spring 2023 with complete
solution
What is a medical record?
A written or electronic record of the important information regarding a paitent.
What does a medical record serve as in healthcare?
A legal document
All information in a medical record is considered what?
Confidential
What is an EMR?
A computerized record
Who states that you have to keep patient information confidential?
HIPAA
What year did HIPAA enforcement begin?
2003
What does patient registration record consists of?
Demographic and Billing Information
What is subjective data?
Obtained from the patient
What are some subjective symptoms?
A symptom that is felt by the patient but is not observable by the examiner.
chest pain, cramping, etc.
What are some objective symptoms?
A symptom that can be observed by an examiner.
Swelling, slurred speech, break out, etc.
What is a symptom?
Any change in the body or its functioning that indicates the presence of disease.
What is included in the medical record reports?
Health history
Physical Examination
ECG report
Diagnostic Procedure
Holter monitor report
Spirometry report
Radiology report
Diagnostic Imaging report
Consultation report
What is the consent to treatment forms used for?
Legal documents required to perform certain procedures or to release information
contained in the patient's medical record
What does it mean to witness a signature?
The MA verified the patient's identity and watched the patient sign the form.
What is the release of medical information form?
A detailed form that must be completed for requests requiring purposes other than PHI.
How will you file a document in reverse chronological order?
, When the most recent document is placed on top or in front of the other, and the oldest
document is on the bottom or at the end of that section.
What is SOAP?
Subjective data
Objective data
Assessment
Plan
When is the health history taken?
Before the physician performs the physical examination
What is the chief complaint?
The symptom causing the patient the most trouble.
What is present illness?
An expansion of the chief complaint
When the MA opens the office, what should he or she do first?
Unlock file cabinets, paper medical files, and medicine cabinets
How might the MA prepare the telephone system for the day's activities?
Notify the answering service that the office is open
Which of the following is usually performed by the MA while closing the office?
Lock the door through which patients entering the office
True or False: When closing the office, some rooms or areas should be locked
including the medical record files.
True
How many folder are in a tickler file?
43
What should be attached to the chart for each patient who is going to be seen
that day in the office?
Charge slip
What is required under HIPAA related to the medical office statement of privacy
practices?
The patient must sign a form acknowledging the opportunity to read or receipt of the
office privacy practices.
Who is responsible for filling out the charge slip?
Physician
What is a fixed amount of money that a patient is required to pay each time he or
she received treatment?
Copayment
When is a patient placed in an examination room?
After the front office paperwork has been completed
What is it called when the medical assistant determines which telephone calls will
go to the physician?
Screening
How do you answer the telephone for the medical office?
Promptly
Can a MA give test results over the telephone?
NO
solution
What is a medical record?
A written or electronic record of the important information regarding a paitent.
What does a medical record serve as in healthcare?
A legal document
All information in a medical record is considered what?
Confidential
What is an EMR?
A computerized record
Who states that you have to keep patient information confidential?
HIPAA
What year did HIPAA enforcement begin?
2003
What does patient registration record consists of?
Demographic and Billing Information
What is subjective data?
Obtained from the patient
What are some subjective symptoms?
A symptom that is felt by the patient but is not observable by the examiner.
chest pain, cramping, etc.
What are some objective symptoms?
A symptom that can be observed by an examiner.
Swelling, slurred speech, break out, etc.
What is a symptom?
Any change in the body or its functioning that indicates the presence of disease.
What is included in the medical record reports?
Health history
Physical Examination
ECG report
Diagnostic Procedure
Holter monitor report
Spirometry report
Radiology report
Diagnostic Imaging report
Consultation report
What is the consent to treatment forms used for?
Legal documents required to perform certain procedures or to release information
contained in the patient's medical record
What does it mean to witness a signature?
The MA verified the patient's identity and watched the patient sign the form.
What is the release of medical information form?
A detailed form that must be completed for requests requiring purposes other than PHI.
How will you file a document in reverse chronological order?
, When the most recent document is placed on top or in front of the other, and the oldest
document is on the bottom or at the end of that section.
What is SOAP?
Subjective data
Objective data
Assessment
Plan
When is the health history taken?
Before the physician performs the physical examination
What is the chief complaint?
The symptom causing the patient the most trouble.
What is present illness?
An expansion of the chief complaint
When the MA opens the office, what should he or she do first?
Unlock file cabinets, paper medical files, and medicine cabinets
How might the MA prepare the telephone system for the day's activities?
Notify the answering service that the office is open
Which of the following is usually performed by the MA while closing the office?
Lock the door through which patients entering the office
True or False: When closing the office, some rooms or areas should be locked
including the medical record files.
True
How many folder are in a tickler file?
43
What should be attached to the chart for each patient who is going to be seen
that day in the office?
Charge slip
What is required under HIPAA related to the medical office statement of privacy
practices?
The patient must sign a form acknowledging the opportunity to read or receipt of the
office privacy practices.
Who is responsible for filling out the charge slip?
Physician
What is a fixed amount of money that a patient is required to pay each time he or
she received treatment?
Copayment
When is a patient placed in an examination room?
After the front office paperwork has been completed
What is it called when the medical assistant determines which telephone calls will
go to the physician?
Screening
How do you answer the telephone for the medical office?
Promptly
Can a MA give test results over the telephone?
NO
