Medical Assistant Certification Exam Guide
The patient registration record contains what information about a patient? - ANSW 1.
Demographic
2. Billing
information
What is the purpose of a health history? - ANSW 1. Determine pts general health
2. To dx and prescribe tx
3. To evaluate tx of an illness
The physical exam report contains information regarding? - ANSW Physician's
assessment of each part of the patient's body.
What is a consultation report? - ANSW After review of a pts medical record and a
exam of the pt, it is a narrative report about a specialist's opinion on a pts condition.
What is a diagnostic procedure report and what type of reports does it contain? -
ANSW Narrative description and interpretation of a diagnostic procedure. Reports it
contains:
1. EKG
2. Holter monitor
3. sigmoidscopy
4. colonoscopy
5. spirometry
6. radiology
7. diagnostic imaging
What is a therapeutic service report? - ANSW Documents the assessment and tx
designed to restore a pts ability to function. Examples include physical, occupational,
and speech therapy.
What reports do Hospital documents contain? - ANSW 1. physical exam of pt report
2. operative report
3. discharge summary report
4. pathology report
5. emergency department report
When is a release of medical information form required? - ANSW When releasing any
information not regarding medical tx, payment, and healthcare operations.
,What is a source oriented medical record? - ANSW A medical record that is organized
into sections based on department, facility, or other source that generated the
document.
What is a Problem oriented medical record? - ANSW Medical record organized by a
pts specific health problems and include a:
1. database
2. problem list
3. plan of action for each problem
4. Progress notes (in SOAP format)
What components does a Health History contain? - ANSW 1. identification data
2. chief complaint
3. present illness
4. past history
5. family history
6. social history
7. Review of Systems (ROS)
What is the purpose of progress notes? - ANSW To update a medical record any time
a patient visits or calls. Anything a patient does is recorded into the chart via the
PROGRESS NOTES, but into different areas of the medical record
What is a medical impression? - ANSW A tentative dx based off pt data; an educated
guess of the dx before the physician is completely certain.
Define Medical Asepsis. - ANSW Practices that are employed to reduce the number
and hinder the transmission of pathogenic microorganisms.
Handwashing refers to washing the hands with? - ANSW detergent soap
Antiseptic handwashing refers to washing hands with? - ANSW antimicrobial soap
Differentiate between RESIDENT and TRANSIENT flora. - ANSW RESIDENT flora are
usually nonpathogenic and reside on the superficial part of skin. TRANSIENT flora are
flora picked up through daily activities and are often pathogenic.
Define occupational exposure. - ANSW Reasonably anticipated exposure to
bloodborne pathogens or other potentially infectious materials that may result from the
performance of an employee's duties.
Define engineering controls. - ANSW All mechanical or objectifiable measures that
reduce health hazards at the workplace; safer medical devices and biohazard
containers.
, Define Work Practice controls - ANSW Measures that reduce health hazards at the
work place by altering a technique or procedure to make it safer.
What are the biggest threats to healthcare workers in the form of occupational
exposure? - ANSW 1. Hepatitis B
2. Hepatitis C
3. HIV
Define parenteral. - ANSW Taken into the body by a break in the skin or mucous
membranes. NOT BY MOUTH
Define Postexposure prophylaxis (PEP). - ANSW Tx to an individual after an exposure
to a disease to prevent that disease.
Define Hazard Communication Standard (HCS). - ANSW Required by OSHA to all
places of employment, a written plan (Hazard communication program) to inform
workers of the hazardous chemicals at their workplace.
What 2 ways can instruments be cleaned? - ANSW 1. Manually
2. Ultrasonic cleaner
How is permanents stains on instruments avoided? - ANSW By not cleaning dissimilar
metals together.
By what means does an ultrasonic cleaner clean instruments? - ANSW 1. cleaning
solution
2. sound waves
Define disinfection. - ANSW Process of destroying pathogenic microbes, but not
bacterial spores.
What are the most commonly used disinfectants in the medical office? - ANSW 1.
glutaraldehyde
2. alcohol
3. sodium hypochlorite (bleach)
4. phenolics
5. quanternary ammonium compounds
Define the 3 levels of disinfection. - ANSW 1. High-level: used to disinfect semi-critical
heat sensitive items
2. Intermediate level: used to disinfect noncritical items
3. Low level: used to disinfect surfaces of the medical facility
What level disinfectant is glutaraldehyde? - ANSW high level
What level disinfectant is isopropyl and ethyl alcohol? - ANSW low to intermediate
The patient registration record contains what information about a patient? - ANSW 1.
Demographic
2. Billing
information
What is the purpose of a health history? - ANSW 1. Determine pts general health
2. To dx and prescribe tx
3. To evaluate tx of an illness
The physical exam report contains information regarding? - ANSW Physician's
assessment of each part of the patient's body.
What is a consultation report? - ANSW After review of a pts medical record and a
exam of the pt, it is a narrative report about a specialist's opinion on a pts condition.
What is a diagnostic procedure report and what type of reports does it contain? -
ANSW Narrative description and interpretation of a diagnostic procedure. Reports it
contains:
1. EKG
2. Holter monitor
3. sigmoidscopy
4. colonoscopy
5. spirometry
6. radiology
7. diagnostic imaging
What is a therapeutic service report? - ANSW Documents the assessment and tx
designed to restore a pts ability to function. Examples include physical, occupational,
and speech therapy.
What reports do Hospital documents contain? - ANSW 1. physical exam of pt report
2. operative report
3. discharge summary report
4. pathology report
5. emergency department report
When is a release of medical information form required? - ANSW When releasing any
information not regarding medical tx, payment, and healthcare operations.
,What is a source oriented medical record? - ANSW A medical record that is organized
into sections based on department, facility, or other source that generated the
document.
What is a Problem oriented medical record? - ANSW Medical record organized by a
pts specific health problems and include a:
1. database
2. problem list
3. plan of action for each problem
4. Progress notes (in SOAP format)
What components does a Health History contain? - ANSW 1. identification data
2. chief complaint
3. present illness
4. past history
5. family history
6. social history
7. Review of Systems (ROS)
What is the purpose of progress notes? - ANSW To update a medical record any time
a patient visits or calls. Anything a patient does is recorded into the chart via the
PROGRESS NOTES, but into different areas of the medical record
What is a medical impression? - ANSW A tentative dx based off pt data; an educated
guess of the dx before the physician is completely certain.
Define Medical Asepsis. - ANSW Practices that are employed to reduce the number
and hinder the transmission of pathogenic microorganisms.
Handwashing refers to washing the hands with? - ANSW detergent soap
Antiseptic handwashing refers to washing hands with? - ANSW antimicrobial soap
Differentiate between RESIDENT and TRANSIENT flora. - ANSW RESIDENT flora are
usually nonpathogenic and reside on the superficial part of skin. TRANSIENT flora are
flora picked up through daily activities and are often pathogenic.
Define occupational exposure. - ANSW Reasonably anticipated exposure to
bloodborne pathogens or other potentially infectious materials that may result from the
performance of an employee's duties.
Define engineering controls. - ANSW All mechanical or objectifiable measures that
reduce health hazards at the workplace; safer medical devices and biohazard
containers.
, Define Work Practice controls - ANSW Measures that reduce health hazards at the
work place by altering a technique or procedure to make it safer.
What are the biggest threats to healthcare workers in the form of occupational
exposure? - ANSW 1. Hepatitis B
2. Hepatitis C
3. HIV
Define parenteral. - ANSW Taken into the body by a break in the skin or mucous
membranes. NOT BY MOUTH
Define Postexposure prophylaxis (PEP). - ANSW Tx to an individual after an exposure
to a disease to prevent that disease.
Define Hazard Communication Standard (HCS). - ANSW Required by OSHA to all
places of employment, a written plan (Hazard communication program) to inform
workers of the hazardous chemicals at their workplace.
What 2 ways can instruments be cleaned? - ANSW 1. Manually
2. Ultrasonic cleaner
How is permanents stains on instruments avoided? - ANSW By not cleaning dissimilar
metals together.
By what means does an ultrasonic cleaner clean instruments? - ANSW 1. cleaning
solution
2. sound waves
Define disinfection. - ANSW Process of destroying pathogenic microbes, but not
bacterial spores.
What are the most commonly used disinfectants in the medical office? - ANSW 1.
glutaraldehyde
2. alcohol
3. sodium hypochlorite (bleach)
4. phenolics
5. quanternary ammonium compounds
Define the 3 levels of disinfection. - ANSW 1. High-level: used to disinfect semi-critical
heat sensitive items
2. Intermediate level: used to disinfect noncritical items
3. Low level: used to disinfect surfaces of the medical facility
What level disinfectant is glutaraldehyde? - ANSW high level
What level disinfectant is isopropyl and ethyl alcohol? - ANSW low to intermediate
