10th Edition by Bonewit-West, (All Chapters Answered)
Chapter .01: .The .Medical .Record
Bonewit-West: .Clinical .Procedures .for .Medical .Assistants, .10th .Edition
MULTIPLE .CHOICE
1. 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
2. What .information .is .contained .in .the .medical .record?
a. Health .history .report
b. Results .of .the .physical .examination
c. Laboratory .reports
d. Progress .notes
e. All .of .the .above
ANS: . E REF: .pp. .2-3| .CAAHEP .Competency .(2015):
.VI.4 .OBJ: .2
3. The .purpose .of .the .HIPAA .Privacy .Rule .is .to
a. reduce .exposure .of .patients .to .bloodborne .pathogens.
b. provide .patients .with .b e t t e rNcUo nRt S
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.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 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.
, 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
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 .laboratoryNtUesRtsStI
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d .by .an .outside .laboratory
ANS: . D REF: .pp. .2-3| .CAAHEP .Competency .(2015):
.VI.4 .OBJ: .2
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
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 .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