Question 1

Subjective or internal conditions felt by the patient are ____.

Accepted Answer

A)  signs 
B)  symptoms 
C)  responses 
D)  goals 
E)  outcomes 
A)  signs 
B)  symptoms 
C)  responses 
D)  goals 
E)  outcomes

Question 2

When should you record exam and test results?

Accepted Answer

A)  Every Friday afternoon 
B)  Every Monday morning 
C)  Every other Friday 
D)  Once a month 
E)  As soon as they are available 
A)  Every Friday afternoon 
B)  Every Monday morning 
C)  Every other Friday 
D)  Once a month 
E)  As soon as they are available

Question 3

The S section of SOAP documentation is ____.

Accepted Answer

A)  data that comes directly from the patient 
B)  the diagnosis or impression of a patient's problem 
C)  the plan of action 
D)  data that comes from the physician or test results 
E)  a description of treatment options 
A)  data that comes directly from the patient 
B)  the diagnosis or impression of a patient's problem 
C)  the plan of action 
D)  data that comes from the physician or test results 
E)  a description of treatment options

Question 4

What does the A in SOAP documentation stand for?

Accepted Answer

A)  Action 
B)  Alternative 
C)  Application 
D)  Assessment 
E)  Adjusted 
A)  Action 
B)  Alternative 
C)  Application 
D)  Assessment 
E)  Adjusted

Question 5

When do most states consider children to be adults with the right to privacy?

Accepted Answer

A)  Age 16 
B)  Age 18 
C)  Age 21 
D)  Age 25 
E)  When the child has a job 
A)  Age 16 
B)  Age 18 
C)  Age 21 
D)  Age 25 
E)  When the child has a job

Question 6

A summary of the reason a patient entered the hospital, the care the patient received in the hospital, and the outcome of the hospitalization is found in the ____.

Accepted Answer

A)  patient medical history 
B)  physician examination form 
C)  patient registration form 
D)  laboratory results 
E)  hospital discharge summary 
A)  patient medical history 
B)  physician examination form 
C)  patient registration form 
D)  laboratory results 
E)  hospital discharge summary

Question 7

The reason a patient's record should not be sent by fax machine is that ____.

Accepted Answer

A)  copies from a fax machine are difficult to read 
B)  there is no way to tell who will see the document 
C)  it takes too long to fax each page 
D)  fax machines are unreliable 
E)  the digital transmission from a fax machine can be corrupted 
A)  copies from a fax machine are difficult to read 
B)  there is no way to tell who will see the document 
C)  it takes too long to fax each page 
D)  fax machines are unreliable 
E)  the digital transmission from a fax machine can be corrupted

Question 8

The informed ________ form verifies that a patient understands the treatment offered and the possible outcomes or side effects of treatment.

Accepted Answer

The answer of The informed ________ form verifies that a...

Question 9

The section of a patient medical history form that contains the patient's description of the current condition or complaint is called the _________of present illness section.

Accepted Answer

The answer of The section of a patient medical history...

Question 10

In the CHEDDAR format of documentation, the C section includes

Accepted Answer

A)  a list of current medications. 
B)  consults. 
C)  presenting problems. 
D)  contributing information. 
E)  assessment of the diagnostic process. 
A)  a list of current medications. 
B)  consults. 
C)  presenting problems. 
D)  contributing information. 
E)  assessment of the diagnostic process.

Question 11

A medical record received from another health provider should be ___.

Accepted Answer

A)  entered into the patient's chart 
B)  placed in a file in the medical office 
C)  given to the patient to keep 
D)  kept in the physician's office for reference 
E)  shredded to maintain confidentiality 
A)  entered into the patient's chart 
B)  placed in a file in the medical office 
C)  given to the patient to keep 
D)  kept in the physician's office for reference 
E)  shredded to maintain confidentiality

Question 12

A patient's illness and the reason for a visit to the medical office are found in the ____.

Accepted Answer

A)  informed consent form 
B)  patient registration form 
C)  records from other healthcare providers 
D)  patient test results 
E)  patient medical history 
A)  informed consent form 
B)  patient registration form 
C)  records from other healthcare providers 
D)  patient test results 
E)  patient medical history

Question 13

Documenting a patient's walk down a hall as "fine" violates which "C" of charting?

Accepted Answer

A)  Completeness 
B)  Clarity 
C)  Conciseness 
D)  Chronological order 
E)  Confidentiality 
A)  Completeness 
B)  Clarity 
C)  Conciseness 
D)  Chronological order 
E)  Confidentiality

Question 14

If an employee of the practice records information inappropriately or inaccurately in a patient's health record, legally the ________ and the employee are held responsible.

Accepted Answer

licensed p

Question 15

Kenneth is preparing copies of X-ray and lab results from Mrs. Vendel's chart to be mailed to another physician's office. He tells you that he thinks this is a waste of time, but Mrs. Vendel called and requested that the records be sent to the other physician's office for a second opinion. How should you respond?

Accepted Answer

A)  "If she likes the second opinion, we may lose Mrs. Vendel's business." 
B)  "It's a good thing she called in person so that she could authorize the transfer." 
C)  "Mrs. Vendel is infamous for wanting second opinions; we do this all the time." 
D)  "I'm not busy right now; do you want any help copying the records?" 
E)  "Has Mrs. Vendel signed a written consent to have the records transferred?" 
A)  "If she likes the second opinion, we may lose Mrs. Vendel's business." 
B)  "It's a good thing she called in person so that she could authorize the transfer." 
C)  "Mrs. Vendel is infamous for wanting second opinions; we do this all the time." 
D)  "I'm not busy right now; do you want any help copying the records?" 
E)  "Has Mrs. Vendel signed a written consent to have the records transferred?"

Exam 11: Medical Records and Documentation

Subjective or internal conditions felt by the patient are ____.

When should you record exam and test results?

The S section of SOAP documentation is ____.

What does the A in SOAP documentation stand for?

When do most states consider children to be adults with the right to privacy?

A summary of the reason a patient entered the hospital, the care the patient received in the hospital, and the outcome of the hospitalization is found in the ____.

The reason a patient's record should not be sent by fax machine is that ____.

The informed ________ form verifies that a patient understands the treatment offered and the possible outcomes or side effects of treatment.

The section of a patient medical history form that contains the patient's description of the current condition or complaint is called the _________of present illness section.

In the CHEDDAR format of documentation, the C section includes

A medical record received from another health provider should be ___.

A patient's illness and the reason for a visit to the medical office are found in the ____.

Documenting a patient's walk down a hall as "fine" violates which "C" of charting?

If an employee of the practice records information inappropriately or inaccurately in a patient's health record, legally the ________ and the employee are held responsible.

Introduction to Medical Assisting

Healthcare and the Healthcare Team

Professionalism and Success

Interpersonal Communication

Legal and Ethical Issues

Infection Control Fundamentals

Safety and Patient Reception

Office Equipment and Supplies

Examination and Treatment Areas

Written and Electronic Communication

Electronic Health Records

Managing Medical Records

Telephone Techniques

Patient Education

Schedule Management

Insurance Billing

Diagnostic Coding

Procedure Coding

Patient Collections and Financial Management

Organization of the Body

The Integumentary System

The Skeletal System

The Muscular System

The Cardiovascular System

The Blood

The Lymphatic and Immune Systems

The Respiratory System

The Nervous System

The Urinary System

The Reproductive Systems

The Digestive System

The Endocrine System

Special Senses

Infection Control Practices

Patient Interview and History

Vital Signs and Measurements

Assisting With a General Physical Exam

Assisting in Reproductive and Urinary Specialties

Assisting in Pediatrics

Assisting in Geriatrics

Assisting in Other Medical Specialties

Assisting in Eye and Ear Care

Assisting in Minor Surgery

Orientation to the Lab

Microbiology and Disease

Processing and Testing Urine and Stool Samples

Collecting, Processing, and Testing Blood Specimens

Electrocardiography and Pulmonary Function Testing

Diagnostic Imaging

Principles of Pharmacology

Math and Dosage Calculations

Medication Administration

Physical Therapy and Rehabilitation

Nutrition and Health

Practice Management

Emergency Preparedness

Preparing for the World of Work

Filters