Question 1

"The patient got out of bed and walked 20 feet without reporting or displaying signs of shortness of breath" is an example of ____ in documentation.

Accepted Answer

A)   clarity
B)   too much detail
C)   breach of confidentiality
D)   using the client's words
E)   lack of completenessF) None of the above
G) B) and D)

Question 2

The best place to interview a patient is ____.

Accepted Answer

A)   in the patient waiting room
B)   in a private room
C)   in the hallway leading to the exam rooms
D)   at the reception desk
E)   at any convenient locationF) None of the above
G) C) and D)

Question 3

The role the medical assistant plays in patient education is to explain ____.

Accepted Answer

A)   test results
B)   what treatment is appropriate
C)   the outcome of the disease
D)   management of the patient's condition as outlined by the practitioner
E)   how the patient should manage pain associated with the conditionF) A) and B)
G) All of the above

Question 4

The appropriate way to delete information on a medical record is to ____.

Accepted Answer

A)   draw a line through the original information so it is still legible
B)   use correction fluid to cover it up
C)   erase the mistaken data
D)   scratch out the incorrect information
E)   retype the entire record, leaving out the information to be deletedF) B) and E)
G) C) and D)

Question 5

The purpose of having a patient sign an informed consent form is to ensure that the ____.

Accepted Answer

A)   patient has a legal recourse against the physician
B)   patient understands the treatment offered and the possible outcomes
C)   physician may terminate care at any time
D)   physician does not have to document every visit
E)   physician can delegate the patient's care to the medical assistantF) A) and E)
G) A) and C)

Question 6

A physical examination form that is used during an "oral examination" to identify any signs or symptoms the patient may be experiencing or reveal information about an illness or condition is called a review of _________ or ROS.

Accepted Answer

The answer of A physical examination form that is used...

Question 7

Information such as laboratory results that are required quickly are commonly sent to the medical facility by which method?

Accepted Answer

A)   Mail
B)   Phone
C)   Fax
D)   Delivery person
E)   Telling the physician what is wrong with the patientF) B) and C)
G) C) and D)

Question 8

Which of the following organizations reviews patient health records to monitor whether the care provided and the fee charged met accepted standards?

Accepted Answer

A)   American Hospital Association
B)   American Medical Society
C)   American Medical Association
D)   Professional Board of Medical Examiners
E)   The Joint CommissionF) A) and C)
G) A) and B)

Question 9

An example of a patient sign is ____.

Accepted Answer

A)   a rash
B)   pain
C)   nausea
D)   a headache
E)   a tingling sensationF) C) and D)
G) D) and E)

Question 10

Whether the medical practice uses conventional or POMR charts, you can use the ________ approach to documentation.

Accepted Answer

The answer of Whether the medical practice uses conventional or...

Question 11

The specific information required of a population that must be obtained when a new patient makes an appointment with the office is ________.

Accepted Answer

The answer of The specific information required of a population...

Question 12

Patient X-ray and lab tests should be placed in the medical record according to facility policy, but always in reverse ________ order.

Accepted Answer

The answer of Patient X-ray and lab tests should be...

Question 13

An example of a patient symptom is ____.

Accepted Answer

A)   pain
B)   high blood pressure
C)   swelling
D)   rash
E)   feverF) All of the above
G) B) and E)

Question 14

What color ink is preferred for handwritten documentation in a patient's medical record?

Accepted Answer

A)   Blue
B)   Black
C)   Red
D)   Purple
E)   BrownF) A) and E)
G) B) and E)

Question 15

To reduce confusion in medical records, ________ are being used less often, except for those that are very clear in meaning.

Accepted Answer

The answer of To reduce confusion in medical records, ________...

Question 16

The most appropriate way to terminate an initial interview with the patient is ____.

Accepted Answer

A)   "The doctor will be in shortly."
B)   "Is there anything else you would like the doctor to know?"
C)   "I need to terminate this interview."
D)   "The lab technician will be in to draw blood."
E)   "Are you sure you haven't forgotten to tell me anything?"F) C) and D)
G) A) and B)

Question 17

In which section of the CHEDDAR format of documentation can the diagnosis be found?

Accepted Answer

A)   Details of problems and complaints
B)   Assessment
C)   Examination
D)   Chief complaint
E)   HistoryF) None of the above
G) A) and B)

Question 18

In addition to being essential documents for patient care management, patient records are used for ____.

Accepted Answer

A)   advertising physician services
B)   providing patient education
C)   evaluating patient satisfaction
D)   showing results to other patients
E)   evaluating public recordsF) C) and E)
G) B) and D)

Question 19

Patient records are used in medical research ____.

Accepted Answer

A)   for data regarding patient responses and side effects
B)   only occasionally, because it is usually considered illegal
C)   for experimentation with treatment that has not yet been approved
D)   as a means to get research money
E)   to determine the average amount being paid for health insuranceF) A) and D)
G) B) and E)

Question 20

Important information about a patient's medical history and present condition is found in the ____.

Accepted Answer

A)   patient's health record
B)   problem-oriented medical record system
C)   medical transcription
D)   medical office record book
E)   scheduling or appointment bookF) A) and B)
G) C) and D)

Exam 11: Medical Records and Documentation

The best place to interview a patient is ____.

Correct AnswerverifiedShow Answer

The appropriate way to delete information on a medical record is to ____.

Correct AnswerverifiedShow Answer

The role the medical assistant plays in patient education is to explain ____.

Correct AnswerverifiedShow Answer

To reduce confusion in medical records, ________ are being used less often, except for those that are very clear in meaning.

Correct AnswerverifiedShow Answer

The purpose of having a patient sign an informed consent form is to ensure that the ____.

Correct AnswerverifiedShow Answer

What color ink is preferred for handwritten documentation in a patient's medical record?

Correct AnswerverifiedShow Answer

The specific information required of a population that must be obtained when a new patient makes an appointment with the office is ________.

Correct AnswerverifiedShow Answer

An example of a patient symptom is ____.

Correct AnswerverifiedShow Answer

"The patient got out of bed and walked 20 feet without reporting or displaying signs of shortness of breath" is an example of ____ in documentation.

Correct AnswerverifiedShow Answer

Information such as laboratory results that are required quickly are commonly sent to the medical facility by which method?

Correct AnswerverifiedShow Answer

In which section of the CHEDDAR format of documentation can the diagnosis be found?

Correct AnswerverifiedShow Answer

Patient X-ray and lab tests should be placed in the medical record according to facility policy, but always in reverse ________ order.

Correct AnswerverifiedShow Answer

A physical examination form that is used during an "oral examination" to identify any signs or symptoms the patient may be experiencing or reveal information about an illness or condition is called a review of _________ or ROS.

Correct AnswerverifiedShow Answer

Patient records are used in medical research ____.

Correct AnswerverifiedShow Answer

An example of a patient sign is ____.

Correct AnswerverifiedShow Answer

Important information about a patient's medical history and present condition is found in the ____.

Correct AnswerverifiedShow Answer

Which of the following organizations reviews patient health records to monitor whether the care provided and the fee charged met accepted standards?

Correct AnswerverifiedShow Answer

The most appropriate way to terminate an initial interview with the patient is ____.

Correct AnswerverifiedShow Answer

In addition to being essential documents for patient care management, patient records are used for ____.

Correct AnswerverifiedShow Answer

Whether the medical practice uses conventional or POMR charts, you can use the ________ approach to documentation.

Correct AnswerverifiedShow Answer

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