TEST BANK FOR Clinical Procedures for Medical Assistants 10th Edition
by Kathy Bonewit-West
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Chapter 01: The Medical Record
MULTIPLE CHOICE
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1. What information is contained in the medical record?
a. Health history report
b. Results of the physical examination
c. Laboratory reports
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d. Progress notes
e. All of the above
ANS: E REF: pp. 2-3| CAAHEP Competency (2015): VI.4
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OBJ: 2
2. 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
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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
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OBJ: 1
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3. The purpose of the HIPAA Privacy Rule is to
a. reduce exposure of patients to bloodborne pathogens.
b. provide patients with betterNcU
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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
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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
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5. Health information in any form that contains patient identifiable information is known as
a. PHI.
b. NPP.
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c. OSHA.
d. HIPAA.
A N
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O
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, 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
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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
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ANS: E REF: p. 4| CAAHEP Competency (2015): IX.3
OBJ: 2
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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
A
ANS: A REF: pp. 2-3| CAAHEP Competency (2015): VI.4
OBJ: 2
N
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
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c. It assists in diagnosing and treating disease
d. It is a request for laboratoryNtU
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d by an outside laboratory
ANS: D REF: pp. 2-3| CAAHEP Competency (2015): VI.4
OBJ: 2
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9. Which of the following is an example of a diagnostic procedure report?
a. Electrocardiogram report
b. Physical therapy report
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c. Urinalysis report
d. Pathology report
ANS: A REF: pp. 2-3| CAAHEP Competency (2015): VI.4
OBJ: 2
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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
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c. Pathology report
d. Therapeutic service report
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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?
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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
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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
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d. Patient instruction sheet
ANS: C REF: pp. 2-3| CAAHEP Competency (2015): VI.4
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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
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d. Retrieval of a medical record
e. All of the above
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ANS: E REF: p. 3| CAAHEP Competency (2015): V.8
OBJ: 3
KS
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.
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ANS: D REF: pp. 3, 6| CAAHEP Competency (2015): VI.12
OBJ: 5
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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
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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?
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a. By scanning them into the computer
b. By retyping them on the computer
c. By photocopying them
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d. By transmitting them through a modem
ANS: A REF: p. 11| CAAHEP Competency (2015): VI.4
OBJ: 8
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