Question 1

The medical record should be released only with a

Accepted Answer

A)  verbal order from the physician. 
B)  written order from the physician. 
C)  written release from the patient. 
D)  verbal order from the office manager. 
A)  verbal order from the physician. 
B)  written order from the physician. 
C)  written release from the patient. 
D)  verbal order from the office manager.

Question 2

Perhaps the most essential action for the medical assistant working with a patient and using an electronic record is to

Accepted Answer

A)  make frequent eye contact with the patient and smile. 
B)  type in every word the patient says. 
C)  make sure the patient is not hiding any part of the health history. 
D)  sit in a chair across from the patient so that the person cannot see the screen. 
A)  make frequent eye contact with the patient and smile. 
B)  type in every word the patient says. 
C)  make sure the patient is not hiding any part of the health history. 
D)  sit in a chair across from the patient so that the person cannot see the screen.

Question 3

HIPAA recommends that physicians keep the records on patients for at least

Accepted Answer

A)  1 year. 
B)  2 years. 
C)  3 years. 
D)  HIPAA does not recommend a number of years. 
A)  1 year. 
B)  2 years. 
C)  3 years. 
D)  HIPAA does not recommend a number of years.

Question 4

Which statement is not accurate about correcting charting errors?

Accepted Answer

A)  Insert the correction above or immediately after the error. 
B)  Draw two clear lines through the error. 
C)  In the margin, initial and date the error correction. 
D)  Do not hide charting errors. 
A)  Insert the correction above or immediately after the error. 
B)  Draw two clear lines through the error. 
C)  In the margin, initial and date the error correction. 
D)  Do not hide charting errors.

Question 5

Usually, more staff members are needed when an office uses an EHR system.

Accepted Answer

A) True 
 B)False

Question 6

The type of electronic record of health-related information about a patient that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff from more than one healthcare organization is a(n)

Accepted Answer

A)  EMH. 
B)  EHR. 
C)  EMR. 
D)  PHI. 
A)  EMH. 
B)  EHR. 
C)  EMR. 
D)  PHI.

Question 7

Which of the following functions of an electronic record can store lists of billing codes and current procedural terminology?

Accepted Answer

A)  Appointment scheduler 
B)  Charge capture 
C)  Referral management 
D)  Medical billing system 
A)  Appointment scheduler 
B)  Charge capture 
C)  Referral management 
D)  Medical billing system

Question 8

The patient owns the medical record.

Accepted Answer

A) True 
 B)False

Question 9

The physical medical record belongs to the

Accepted Answer

A)  patient. 
B)  physician or provider. 
C)  insurance company. 
D)  All of the above 
A)  patient. 
B)  physician or provider. 
C)  insurance company. 
D)  All of the above

Question 10

Information that is gained by questioning the patient or that is taken from a form is called ________________ information.

Accepted Answer

A)  confidential 
B)  subjective 
C)  objective 
D)  necessary 
A)  confidential 
B)  subjective 
C)  objective 
D)  necessary

Question 11

Numeric filing provides extra confidentiality to medical records.

Accepted Answer

A) True 
 B)False

Question 12

Which of the following are common types of filing equipment found in a medical office?

Accepted Answer

A)  Rotary circular files 
B)  Lateral files 
C)  Automated files 
D)  All of the above 
A)  Rotary circular files 
B)  Lateral files 
C)  Automated files 
D)  All of the above

Question 13

The American Recovery and Reinvestment Act of 2009 is commonly known as the Economic Stimulus Package and was meant to promote economic recovery.

Accepted Answer

A) True 
 B)False

Question 14

Which statement is not true regarding the reasons for keeping accurate medical records?

Accepted Answer

A)  The medical record provides critical information for other caregivers. 
B)  Effects of various treatments can be tracked and statistics gleaned from them. 
C)  The patient's family may want to examine the records and correct errors. 
D)  Accurate records are vital for financial reimbursements. 
A)  The medical record provides critical information for other caregivers. 
B)  Effects of various treatments can be tracked and statistics gleaned from them. 
C)  The patient's family may want to examine the records and correct errors. 
D)  Accurate records are vital for financial reimbursements.

Question 15

The newest component used today to complete transcription and authenticate records is __________ software.

Accepted Answer

A)  voice-activated 
B)  voice recognition 
C)  voice registry 
D)  voice-controlled 
A)  voice-activated 
B)  voice recognition 
C)  voice registry 
D)  voice-controlled

Question 16

In a paper record, which of the following is never an acceptable method of correction to a handwritten entry?

Accepted Answer

A)  Draw a line through the error. 
B)  Erase or use a correction fluid. 
C)  Insert the correction above the error. 
D)  Write initials or signature below the correction and date. 
E)  All of the above are acceptable. 
A)  Draw a line through the error. 
B)  Erase or use a correction fluid. 
C)  Insert the correction above the error. 
D)  Write initials or signature below the correction and date. 
E)  All of the above are acceptable.

Question 17

A provisional diagnosis is not a final diagnosis and usually is made before test results are received.

Accepted Answer

A) True 
 B)False

Question 18

How would you properly index the name "Amanda M. Stiles-Duncan" for filing?

Accepted Answer

A)  Stilesduncan, Amanda M. 
B)  Stiles Duncan, Amanda M. 
C)  Duncanstiles, Amanda M. 
D)  Duncan, Amanda M. Stiles 
A)  Stilesduncan, Amanda M. 
B)  Stiles Duncan, Amanda M. 
C)  Duncanstiles, Amanda M. 
D)  Duncan, Amanda M. Stiles

Question 19

A filing system in which an intermediary source of reference, such as a file card, must be consulted to locate specific files is called a(n) _____________ system.

Accepted Answer

A)  shelf filing 
B)  indirect filing 
C)  direct filing 
D)  shingling 
A)  shelf filing 
B)  indirect filing 
C)  direct filing 
D)  shingling

Question 20

Advantages of the EHR system include

Accepted Answer

A)  ability of the physician to see more patients in a day. 
B)  cost of implementation. 
C)  possibility of a breach of confidentiality. 
D)  concern of patients over privacy. 
A)  ability of the physician to see more patients in a day. 
B)  cost of implementation. 
C)  possibility of a breach of confidentiality. 
D)  concern of patients over privacy.

Exam 11: The Health Record

The medical record should be released only with a

Perhaps the most essential action for the medical assistant working with a patient and using an electronic record is to

HIPAA recommends that physicians keep the records on patients for at least

Which statement is not accurate about correcting charting errors?

Usually, more staff members are needed when an office uses an EHR system.

The type of electronic record of health-related information about a patient that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff from more than one healthcare organization is a(n)

Which of the following functions of an electronic record can store lists of billing codes and current procedural terminology?

The patient owns the medical record.

The physical medical record belongs to the

Information that is gained by questioning the patient or that is taken from a form is called ________________ information.

Numeric filing provides extra confidentiality to medical records.

Which of the following are common types of filing equipment found in a medical office?

The American Recovery and Reinvestment Act of 2009 is commonly known as the Economic Stimulus Package and was meant to promote economic recovery.

Which statement is not true regarding the reasons for keeping accurate medical records?

The newest component used today to complete transcription and authenticate records is __________ software.

In a paper record, which of the following is never an acceptable method of correction to a handwritten entry?

A provisional diagnosis is not a final diagnosis and usually is made before test results are received.

How would you properly index the name "Amanda M. Stiles-Duncan" for filing?

A filing system in which an intermediary source of reference, such as a file card, must be consulted to locate specific files is called a(n) _____________ system.

Advantages of the EHR system include

Competency-Based Education and the Medical Assistant Student

The Medical Assistant and the Healthcare Team

Professional Behavior in the Workplace

Therapeutic Communications

Medicine and Law

Medicine and Ethics

Technology and Written Communication in the Medical Office

Telephone Techniques

Scheduling Appointments and Patient Processing

Daily Operations in the Ambulatory Care Setting

Basics of Diagnostic Coding

Basics of Procedural Coding

Basics of Health Insurance

Medical Billing and Reimbursement

Patient Accounts, Collections, and Practice Management

Banking Services and Procedures

Supervision and Human Resources Management

Medical Practice Marketing and Customer Service

Infection Control

Patient Assessment

Patient Education

Nutrition and Health Promotion

Vital Signs

Assisting With the Primary Physical Examination

Principles of Pharmacology

Pharmacology Math

Administering Medications

Safety and Emergency Practices

Assisting in Ophthalmology and Otolaryngology

Assisting in Dermatology

Assisting in Gastroenterology

Assisting in Urology and Male Reproduction

Assisting in Obstetrics and Gynecology

Assisting in Pediatrics

Assisting in Orthopedic Medicine

Assisting in Neurology and Mental Health

Assisting in Endocrinology

Assisting in Pulmonary Medicine

Assisting in Cardiology

Assisting in Geriatrics

Principles of Electrocardiography

Assisting With Diagnostic Imaging

Assisting in the Clinical Laboratory

Assisting in the Analysis of Urine

Assisting in Blood Collection

Assisting in the Analysis of Blood

Assisting in Microbiology and Immunology

Surgical Supplies and Instruments

Surgical Asepsis and Assisting With Surgical Procedures

Career Development and Life Skills

Filters