Test Bank For
Clinical Procedures for Medical Assistants, 11th Edition Copyright 2024 by Kathy Bonewit-West
Chapter 1-23
Chapter 01: The Medical Record and Health History
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: CAAHEP Competency: VI.6
2. What information is contained in the medical record?
a. Health history report
b. Physical examination report
c. Laboratory reports
d. Progress notes
e. All of these
ANS: E REF: CAAHEP Competency: VI.6
3. The purpose of the HIPAA Privacy Rule is to
a. Reduce exposure of patients to bloodborne pathogens.
b. Provide patients with better control over the use and disclosure of their 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: CAAHEP Competency: X.3
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 acknowledgement from the patient that he/she has received
an NPP
ANS: A REF: CAAHEP Competency: X.3
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: CAAHEP Competency: V.8.b.
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 these
ANS: E REF: CAAHEP Competency: X.3
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: CAAHEP Competency: VI.6
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 laboratory tests to be performed by an outside laboratory.
ANS: D REF: CAAHEP Competency: I.8.d. | CAAHEP Competency: V.8.a.
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: CAAHEP Competency: I.8.d.
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: CAAHEP Competency: V.8.a.
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: CAAHEP Competency: VI.6
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: CAAHEP Competency: X.13.a.
13. Which of the following can be performed by an EHR 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 these
ANS: E REF: CAAHEP Competency: VI.6
14. All of the following are advantages of an electronic health record (EHR) except:
a. An EHR does not have to be filed.
b. Documents in an EHR can be quickly retrieved.
c. Paper costs are reduced.
d. EMRs are exempt from the HIPAA regulations.
ANS: D REF: CAAHEP Competency: VI.6
15. Which of the following are used to enter data into an EHR?
a. Free-text entry
b. Drop-down menus
c. Radio buttons
d. All of these
ANS: D REF: CAAHEP Competency: VI.6
16. Which of the following is not a characteristic of a patient portal?
a. It is a secure online website.
b. Provides patients with 24-hour access to their personal health information.
c. Patients can access health information on family members.
d. Patients can view and print their health information.
ANS: C REF: CAAHEP Competency: V.7
17. Which of the following tasks can be performed by a patient using a patient portal?
a. Request prescription refills
b. Check benefits and coverage
c. Complete forms
d. Update contact information
e. All of these
ANS: E REF: CAAHEP Competency: V.7
, 18. All of the following assist in the collection of data for a health history except:
a. A quiet, comfortable room
b. Showing interest in the patient
c. Showing concern for the patient
d. Calling the patient “honey”
ANS: D REF: CAAHEP Competency: V.4
19. Which of the following can be used to enter a health history into an EHR?
a. The patient completes a paper form and the medical assistant scans it into the
computer.
b. The medical assistant enters information into the computer while asking the patient
questions.
c. The patient completes a health history questionnaire on a computer.
d. All of these.
ANS: D REF: CAAHEP Competency: V.7
20. What is a health history?
a. A legal document required to perform certain procedures on a patient
b. Documentation of the results of the physical examination
c. A collection of subjective data about the patient
d. A narrative description and interpretation of a diagnostic procedure
ANS: C REF: CAAHEP Competency: V.8.a.
21. The health history is taken
a. After the provider performs the physical examination.
b. After laboratory test results are reviewed.
c. Before the provider performs the physical examination.
d. After the provider makes a diagnosis of the patient’s condition.
ANS: C REF: CAAHEP Competency: I.11
22. What is the chief complaint?
a. The probable outcome of the patient’s condition
b. The symptom causing the patient the most trouble
c. A detailed description of the patient’s illness using medical terms
d. A tentative diagnosis of the patient’s condition
ANS: B REF: CAAHEP Competency: V.8.a.
23. Which of the following questions should be used to elicit the chief complaint from a
patient?
a. Where does it hurt?
b. Are you sick?
c. How long have you been ill?
d. What seems to be the problem?
e. All of these
ANS: D REF: CAAHEP Competency: V.1
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