Professional Medical Coding and Billing
Final Exam 2 correctly answered to pass
The documentation type that contains various types of analyses or examinations of body
substances collected from the patient.
- History and Physical
- Physician Progress Note
- Operative Report
- Laboratory Report - correct answer ✔✔Laboratory Report
This documentation provides an opinion about a patient's condition from a physician other than
the primary care (attending) physician.
- Consultation
- Nurse's Note
- Face Sheet
- Medication Administration Record - correct answer ✔✔Consultation
A review of the medical record to ensure the standards are met and to determine accuracy of
record documentation.
- Retrospective review
- Annual audit
- Quantitative analysis
- Qualitative analysis - correct answer ✔✔Qualitative analysis
,In reference to a medical report, the acronym SOAP stands for:
- Subjective, Objective, Assessment and Proposal
- Subjective, Objective, Appraisal and Plan
- Subjective, Objective, Assessment and Plan
- Suggestive, Objective, Assessment and Plan - correct answer ✔✔Subjective, Objective,
Assessment and Plan
Which of the following is a common documentation error?
- Date and location inconsistencies
- Missing physician signatures
- Incorrect patient identification
- All of the above - correct answer ✔✔All of the above
Which of the following is true in regard to the release of protected health information (ROI)?
- Covered entities must provide access to the PHI requested no later than 45 calendar days from
receipt of request
- A covered entity must provide access to PHI in the manner requested by the individual
- The fee for copying PHI may include costs associated with searching for and retrieving the PHI
- HIPAA requirements always supercede state laws in regard to how long a covered entitiy has to
provide a copy of PHI - correct answer ✔✔A covered entity must provide access to PHI in the
manner requested by the individual
Which of the following is NOT considered a patient demographic?
, - Date of birth
- Insurance information
- Telephone number
- Mother's maiden name - correct answer ✔✔Mother's maiden name
The physician who has been assigned to a patient and has assumed primary responsibility for
the treatment and care of the patient:
- Consulting physician
- Attending physician
- General physician
- Surgeon - correct answer ✔✔Attending physician
Which organization is responsible for tracking incidence of sexually transmitted disease?
- Center for Medicare and Medicaid Services
- American College of Surgeons
- State agencies
- Local vital statistics office - correct answer ✔✔State agencies
Which of the following would track a patient who has basal cell carcinoma of the abdomen
wall?
- Trauma Registry
- Immunization Registry
- Insulin-Dependent Diabetes Mellitus Registries
Final Exam 2 correctly answered to pass
The documentation type that contains various types of analyses or examinations of body
substances collected from the patient.
- History and Physical
- Physician Progress Note
- Operative Report
- Laboratory Report - correct answer ✔✔Laboratory Report
This documentation provides an opinion about a patient's condition from a physician other than
the primary care (attending) physician.
- Consultation
- Nurse's Note
- Face Sheet
- Medication Administration Record - correct answer ✔✔Consultation
A review of the medical record to ensure the standards are met and to determine accuracy of
record documentation.
- Retrospective review
- Annual audit
- Quantitative analysis
- Qualitative analysis - correct answer ✔✔Qualitative analysis
,In reference to a medical report, the acronym SOAP stands for:
- Subjective, Objective, Assessment and Proposal
- Subjective, Objective, Appraisal and Plan
- Subjective, Objective, Assessment and Plan
- Suggestive, Objective, Assessment and Plan - correct answer ✔✔Subjective, Objective,
Assessment and Plan
Which of the following is a common documentation error?
- Date and location inconsistencies
- Missing physician signatures
- Incorrect patient identification
- All of the above - correct answer ✔✔All of the above
Which of the following is true in regard to the release of protected health information (ROI)?
- Covered entities must provide access to the PHI requested no later than 45 calendar days from
receipt of request
- A covered entity must provide access to PHI in the manner requested by the individual
- The fee for copying PHI may include costs associated with searching for and retrieving the PHI
- HIPAA requirements always supercede state laws in regard to how long a covered entitiy has to
provide a copy of PHI - correct answer ✔✔A covered entity must provide access to PHI in the
manner requested by the individual
Which of the following is NOT considered a patient demographic?
, - Date of birth
- Insurance information
- Telephone number
- Mother's maiden name - correct answer ✔✔Mother's maiden name
The physician who has been assigned to a patient and has assumed primary responsibility for
the treatment and care of the patient:
- Consulting physician
- Attending physician
- General physician
- Surgeon - correct answer ✔✔Attending physician
Which organization is responsible for tracking incidence of sexually transmitted disease?
- Center for Medicare and Medicaid Services
- American College of Surgeons
- State agencies
- Local vital statistics office - correct answer ✔✔State agencies
Which of the following would track a patient who has basal cell carcinoma of the abdomen
wall?
- Trauma Registry
- Immunization Registry
- Insulin-Dependent Diabetes Mellitus Registries
