Question 1

Which of the following is NOT a method used for charting?

Accepted Answer

A) CHEDDAR 
B) SWISS 
C) SOAP 
D) SOAPER 
A) CHEDDAR 
B) SWISS 
C) SOAP 
D) SOAPER

Question 2

Which of the following is NOT part of the provider's notice of its privacy act according to the HIPAA privacy rule?

Accepted Answer

A) Describes patient's rights 
B) Explains facilities practices related to PHI 
C) Explains where to file a complaint 
D) Describes various treatments 
A) Describes patient's rights 
B) Explains facilities practices related to PHI 
C) Explains where to file a complaint 
D) Describes various treatments

Question 3

When you ask the patient questions in the history interview, what is the MOST important consideration?

Accepted Answer

A) That the patient answer each question 
B) That the patient understand each question 
C) That the patient be allowed to decline to answer 
D) That all questions be repeated 
A) That the patient answer each question 
B) That the patient understand each question 
C) That the patient be allowed to decline to answer 
D) That all questions be repeated

Question 4

Match the content for each area of the SOAP chart notes with the appropriate description.

-subjective

Accepted Answer

A)  weigh subjective and objective findings 
B)  vital signs 
C)  symptoms and patient's complaint 
D)  further tests and treatment 
A)  weigh subjective and objective findings 
B)  vital signs 
C)  symptoms and patient's complaint 
D)  further tests and treatment

Question 5

Which is NOT a vulnerable area that HIPAA regulations focus on in regard to medical records and the patient's chart?

Accepted Answer

A) Paper record storage 
B) Fax machines 
C) Photocopies 
D) Workstations 
A) Paper record storage 
B) Fax machines 
C) Photocopies 
D) Workstations

Question 6

Which of the following is the most appropriate action when the medical assistant is taking the medical history?

Accepted Answer

A) Ask the patient whether there are any questions. 
B) Use medical jargon when possible. 
C) Be firm and inflexible. 
D) Ask intimate questions right away to get them over with. 
A) Ask the patient whether there are any questions. 
B) Use medical jargon when possible. 
C) Be firm and inflexible. 
D) Ask intimate questions right away to get them over with.

Question 7

Match the charting symbols/abbreviations with the correct meaning.

-change

Accepted Answer

A)  po 
B)  WNL 
C)  XR 
D)  Δ 
A)  po 
B)  WNL 
C)  XR 
D)  Δ

Question 8

What is the correct order for information placed chronologically in the chart?

Accepted Answer

A) Primary providers notes, EKGs and x-rays, laboratory reports, pathology reports 
B) Primary providers notes, EKGs and x-rays, hospital notes, consultations, correspondence 
C) Primary providers notes, laboratory reports, pathology reports, hospital notes 
D) Primary providers notes, laboratory reports, pathology reports, consultations 
E) Primary providers notes, hospital notes, laboratory reports, medications 
A) Primary providers notes, EKGs and x-rays, laboratory reports, pathology reports 
B) Primary providers notes, EKGs and x-rays, hospital notes, consultations, correspondence 
C) Primary providers notes, laboratory reports, pathology reports, hospital notes 
D) Primary providers notes, laboratory reports, pathology reports, consultations 
E) Primary providers notes, hospital notes, laboratory reports, medications

Question 9

Match the content for each area of the SOAP chart notes with the appropriate description.

-assessment

Accepted Answer

A)  weigh subjective and objective findings 
B)  vital signs 
C)  symptoms and patient's complaint 
D)  further tests and treatment 
A)  weigh subjective and objective findings 
B)  vital signs 
C)  symptoms and patient's complaint 
D)  further tests and treatment

Question 10

Match the content for each area of the SOAP chart notes with the appropriate description.

-plan

Accepted Answer

A)  weigh subjective and objective findings 
B)  vital signs 
C)  symptoms and patient's complaint 
D)  further tests and treatment 
A)  weigh subjective and objective findings 
B)  vital signs 
C)  symptoms and patient's complaint 
D)  further tests and treatment

Question 11

Information such as the patient's full name, address, and telephone number would be found on what form?

Accepted Answer

A) Medical history form 
B) Financial information form 
C) Insurance form 
D) Demographic data form 
A) Medical history form 
B) Financial information form 
C) Insurance form 
D) Demographic data form

Question 12

Match the major contents of the medical history with the appropriate descriptions.

-occupation, hobbies, and drug habits

Accepted Answer

A)  present illness 
B)  medical history 
C)  family history 
D)  social history 
A)  present illness 
B)  medical history 
C)  family history 
D)  social history

Question 13

Which of the following best describe the major components of the problem-oriented medical record?

Accepted Answer

A) Problem list, diagnostic and treatment plan, progress notes 
B) Database, problem list, diagnostic and treatment plan 
C) Database, problem list, diagnostic and treatment plan, progress notes 
D) Database, problem list, diagnostic and treatment plan, laboratory reports 
E) Problem list, diagnostic and treatment plan, progress notes, laboratory reports 
A) Problem list, diagnostic and treatment plan, progress notes 
B) Database, problem list, diagnostic and treatment plan 
C) Database, problem list, diagnostic and treatment plan, progress notes 
D) Database, problem list, diagnostic and treatment plan, laboratory reports 
E) Problem list, diagnostic and treatment plan, progress notes, laboratory reports

Question 14

Match the charting symbols/abbreviations with the correct meaning.

-x-ray

Accepted Answer

A)  po 
B)  WNL 
C)  XR 
D)  Δ 
A)  po 
B)  WNL 
C)  XR 
D)  Δ

Question 15

Which of the following components of the review of systems would include change in speech?

Accepted Answer

A) Neurological 
B) Cardiovascular 
C) Musculoskeletal 
D) Gastrointestinal 
E) Respiratory 
A) Neurological 
B) Cardiovascular 
C) Musculoskeletal 
D) Gastrointestinal 
E) Respiratory

Question 16

Which of the following best describes the first responsibility of the medical assistant when taking the medical history?

Accepted Answer

A) Wash hands. 
B) Allow freedom of conversation. 
C) Put the patient at ease. 
D) Follow the exact order of the history form. 
E) Obtain personal information first. 
A) Wash hands. 
B) Allow freedom of conversation. 
C) Put the patient at ease. 
D) Follow the exact order of the history form. 
E) Obtain personal information first.

Question 17

Which of the following statements is true about interviewing?

Accepted Answer

A) Do not worry about comfort level. 
B) Allow the patient to tell anecdotes. 
C) Do not waste time explaining terms or concepts. 
D) Guide the conversation and keep it on track. 
A) Do not worry about comfort level. 
B) Allow the patient to tell anecdotes. 
C) Do not waste time explaining terms or concepts. 
D) Guide the conversation and keep it on track.

Question 18

Which of the following is the most appropriate action in order to make a correction when an error has been made in the chart?

Accepted Answer

A) Cover with Wite-Out®, write over it, and initial and date it. 
B) Erase the error and correct it. 
C) Scribble out the error and write above it. 
D) Draw a single line through the error.Write the correct entry and put initials and date. 
A) Cover with Wite-Out®, write over it, and initial and date it. 
B) Erase the error and correct it. 
C) Scribble out the error and write above it. 
D) Draw a single line through the error.Write the correct entry and put initials and date.

Question 19

You have picked up your equipment and the supplies necessary to obtain a medical history from a new patient.You introduce yourself to the patient after confirming her identity.Then you attempt to put her at ease.What is the next thing you should do?

Accepted Answer

A) Wash your hands. 
B) Begin to ask questions. 
C) Explain the purpose and importance of information gathering. 
D) Ask about allergies. 
A) Wash your hands. 
B) Begin to ask questions. 
C) Explain the purpose and importance of information gathering. 
D) Ask about allergies.

Question 20

In the SOAPER charting method, what does the letter "E" represent?

Accepted Answer

A) Examination 
B) Early history 
C) Education 
D) Elaboration 
A) Examination 
B) Early history 
C) Education 
D) Elaboration

Exam 22: The Patient History and Documentation

Which of the following is NOT a method used for charting?

Which of the following is NOT part of the provider's notice of its privacy act according to the HIPAA privacy rule?

When you ask the patient questions in the history interview, what is the MOST important consideration?

Match the content for each area of the SOAP chart notes with the appropriate description. -subjective

Which is NOT a vulnerable area that HIPAA regulations focus on in regard to medical records and the patient's chart?

Which of the following is the most appropriate action when the medical assistant is taking the medical history?

Match the charting symbols/abbreviations with the correct meaning. -change

What is the correct order for information placed chronologically in the chart?

Match the content for each area of the SOAP chart notes with the appropriate description. -assessment

Match the content for each area of the SOAP chart notes with the appropriate description. -plan

Information such as the patient's full name, address, and telephone number would be found on what form?

Match the major contents of the medical history with the appropriate descriptions. -occupation, hobbies, and drug habits

Which of the following best describe the major components of the problem-oriented medical record?

Match the charting symbols/abbreviations with the correct meaning. -x-ray

Which of the following components of the review of systems would include change in speech?

Which of the following best describes the first responsibility of the medical assistant when taking the medical history?

Which of the following statements is true about interviewing?

Which of the following is the most appropriate action in order to make a correction when an error has been made in the chart?

You have picked up your equipment and the supplies necessary to obtain a medical history from a new patient.You introduce yourself to the patient after confirming her identity.Then you attempt to put her at ease.What is the next thing you should do?

In the SOAPER charting method, what does the letter "E" represent?

The Medical Assisting Profession

Health Care Settings and the Health Care Team

Coping Skills for the Medical Assistant

Therapeutic Communication Skills

The Therapeutic Approach to the Patient With a Life-Threatening Illness

Legal Considerations

Ethical Considerations

Emergency Procedures and First Aid

Creating the Facility Environment

Computers in the Medical Clinic

Telecommunications

Patient Scheduling

Medical Records Management

Written Communications

Medical Documents

Medical Insurance

Medical Coding

Daily Financial Practices

Billing and Collections

Accounting Practices

Infection Control and Medical Asepsis

Vital Signs and Measurements

The Physical Examination

Obstetrics and Gynecology

Pediatrics

Male Reproductive System

Gerontology

Examinations and Procedures of Body Systems

Assisting With Minor Surgery

Diagnostic Imaging

Rehabilitation and Therapeutic Modalities

Nutrition in Health and Disease

Basic Pharmacology

Calculation of Medication Dosage and Medication Administration

Cardiac Procedures

Regulatory Guidelines for Safety and Quality in the Medical Laboratory

Introduction to the Medical Laboratory

Phlebotomy: Venipuncture and Capillary Puncture

Hematology

Urinalysis

Basic Microbiology

Speciality Laboratory Tests

The Medical Assistant As Clinic Manager

The Medical Assistant As Human Resources Manager

Preparing for Medical Assisting Credentials

Employment Strategies

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