Chapter 36 Exam Clinical Procedures
Questions and Answers
Which of the following is a physical therapy service? - ANSWER-Hydrotherapy
Which of the following helps a patient with a disability learn new ways to perform
skills such as dressing or cooking? - ANSWER-Occupational therapy
What term is used to describe a patient who has been admitted to the hospital for at
least one overnight stay? - ANSWER-Inpatient
What term might be used before there is enough information to make a definitive
diagnosis? - ANSWER-Medical impressions
Which of the following describes a surgical procedure? - ANSWER-Operative report
Which of the following reports consists of an account of the significant events of a
patient's hospitalization? - ANSWER-Discharge summary report
Which of the following reports consists of a macroscopic and microscopic description
of tissue removed during surgery? - ANSWER-Pathology report
Who receives a copy of the patient's emergency department report? - ANSWER-
Patient's family physician
What procedure requires a consent to treatment form? - ANSWER-Sebaceous cyst
removal
Which of the following must be included in informed consent? - ANSWER-An
explanation of risks involved with the procedure
alternative treatments or procedures available
The prognosis
The purpose of the recommended procedure
all of the above
When a medical assistant witnesses a patient's signature, it means that he or she -
ANSWER-Verified the patient's identity and watched the patient sign the form
Which of the following situations requires the completion of a release of medical
information form? - ANSWER-When a patient transfers records to a new physician
, Which of the following is NOT included on a release of medical information form? -
ANSWER-Medications being taken by the patient
Which of the following can be performed by an electronic medical record software
program? - ANSWER-Creation of a medical record
Storage of a medical record
Editing of a medical record
Retrieval of a medical record
All of the above
In a source-oriented record, a radiology report is filed under which of the following
chart dividers? - ANSWER-lab/x-ray
With reverse chronological order, the most recent document is - ANSWER-Placed in
front of the other documents
Which of the following is NOT included in the database section of a POR? -
ANSWER-Plan of treatment
The acronym for the format used to organize POR progress notes is - ANSWER-
SOAP
Data obtained from the patient are recorded in POR progress notes under -
ANSWER-Subjective data
The physician's interpretation of the patient's condition is recorded in POR progress
notes under - ANSWER-assessment
The purpose of the tab on a file folder is to - ANSWER-Identify the contents of the
folder
Which of the following does NOT assist in the collection of data for a health history? -
ANSWER-Calling the patient "honey"
Which of the following can be used to enter a health history into an electronic
medical record? - ANSWER-The patient completes a paper form, and the medical
assistant scans it into the computer.
The medical assistant enters information while asking the patient questions.
The patient completes a health history on a computer.
all of the above
The health history is taken - ANSWER-Before the physician performs the physical
examination
What is the chief complaint? - ANSWER-The symptom causing the patient the most
trouble
Questions and Answers
Which of the following is a physical therapy service? - ANSWER-Hydrotherapy
Which of the following helps a patient with a disability learn new ways to perform
skills such as dressing or cooking? - ANSWER-Occupational therapy
What term is used to describe a patient who has been admitted to the hospital for at
least one overnight stay? - ANSWER-Inpatient
What term might be used before there is enough information to make a definitive
diagnosis? - ANSWER-Medical impressions
Which of the following describes a surgical procedure? - ANSWER-Operative report
Which of the following reports consists of an account of the significant events of a
patient's hospitalization? - ANSWER-Discharge summary report
Which of the following reports consists of a macroscopic and microscopic description
of tissue removed during surgery? - ANSWER-Pathology report
Who receives a copy of the patient's emergency department report? - ANSWER-
Patient's family physician
What procedure requires a consent to treatment form? - ANSWER-Sebaceous cyst
removal
Which of the following must be included in informed consent? - ANSWER-An
explanation of risks involved with the procedure
alternative treatments or procedures available
The prognosis
The purpose of the recommended procedure
all of the above
When a medical assistant witnesses a patient's signature, it means that he or she -
ANSWER-Verified the patient's identity and watched the patient sign the form
Which of the following situations requires the completion of a release of medical
information form? - ANSWER-When a patient transfers records to a new physician
, Which of the following is NOT included on a release of medical information form? -
ANSWER-Medications being taken by the patient
Which of the following can be performed by an electronic medical record software
program? - ANSWER-Creation of a medical record
Storage of a medical record
Editing of a medical record
Retrieval of a medical record
All of the above
In a source-oriented record, a radiology report is filed under which of the following
chart dividers? - ANSWER-lab/x-ray
With reverse chronological order, the most recent document is - ANSWER-Placed in
front of the other documents
Which of the following is NOT included in the database section of a POR? -
ANSWER-Plan of treatment
The acronym for the format used to organize POR progress notes is - ANSWER-
SOAP
Data obtained from the patient are recorded in POR progress notes under -
ANSWER-Subjective data
The physician's interpretation of the patient's condition is recorded in POR progress
notes under - ANSWER-assessment
The purpose of the tab on a file folder is to - ANSWER-Identify the contents of the
folder
Which of the following does NOT assist in the collection of data for a health history? -
ANSWER-Calling the patient "honey"
Which of the following can be used to enter a health history into an electronic
medical record? - ANSWER-The patient completes a paper form, and the medical
assistant scans it into the computer.
The medical assistant enters information while asking the patient questions.
The patient completes a health history on a computer.
all of the above
The health history is taken - ANSWER-Before the physician performs the physical
examination
What is the chief complaint? - ANSWER-The symptom causing the patient the most
trouble
