Question 1

What is the primary function of the clinical record?

Accepted Answer

A)  To provide a dental history for the patient
B)  To provide identification of the patient
C)  To document dental treatment
D)  To provide a total picture of the patient and the patient's needs D

Question 2

New patients should be instructed to arrive _______ early to complete paperwork if they are unable to complete the registration and medical history forms before arriving for their first appointment.

Accepted Answer

A)  5 minutes
B)  15 minutes
C)  30 minutes
D)  60 minutes B

Question 3

Which of the following forms provides the dental practice with the patient's demographic and financial information?

Accepted Answer

A)  The patient registration form
B)  The comprehensive medical history
C)  The dental history
D)  The treatment plan A

Question 4

Which of the following is NOT an advantage of computer-generated clinical records?

Accepted Answer

A)  The dental practice will not need to employ an administrative assistant.
B)  Entries are automatically signed with the code of the person making the entry.
C)  All needed information must be entered before the program can be closed.
D)  Computer-generated progress notes are more easily read than handwritten entries.

Question 5

The key elements of record keeping include organization,completeness,and:

Accepted Answer

A)  accuracy.
B)  consistency.
C)  neatness.
D)  accessibility.

Question 6

What is the most important reason why complete medical history is taken before dental treatment is provided?

Accepted Answer

A)  It should not be taken because it violates the patient's confidentiality.
B)  So the dentist will be aware of any medication the patient is taking
C)  Because the patient's medical doctors are reluctant to release information to a dental office
D)  Careful review of medical history will alert the dentist to possible interactions between dental and medical treatment.

Question 7

The clinical chart notation NSF is an abbreviation for ______.

Accepted Answer

The answer of The clinical chart notation NSF is an...

Question 8

The primary reason for carefully maintaining clinical records is to:

Accepted Answer

A)  Support the need for dental treatment
B)  Justify the actions of the dentist
C)  Provide information for forensic odontology
D)  Both A and B

Question 9

Which of the following is not included in the written privacy procedures?

Accepted Answer

A)  Which members of the staff will have access to private health information
B)  How private health information will be used
C)  Where off-site computer backups are located
D)  When private health information may be disclosed

Question 10

The component of the patient clinical record that is considered "a necessary form" is the:

Accepted Answer

A)  correspondence log.
B)  signature on the file form.
C)  registration form.
D)  treatment plan form.

Question 11

Diagnostic models are:

Accepted Answer

A)  stored in the patient clinical record.
B)  used to provide patient teaching.
C)  casts of the patient's mouth.
D)  used for practice in a dental assisting class.

Question 12

The dental healthcare team can lessen the likelihood of a malpractice suit through _______,a process of identifying procedures that are not in compliance with mandated regulations.

Accepted Answer

A)  treatment planning
B)  cross-referencing
C)  risk management
D)  hazard assessment

Question 13

Match between columns
                        Premises: Emergency access procedures
Protection of electronic systems from environmental hazards
Security incident procedures
Staff clearance procedure that identifies staff members who have access to EPHI
Unique user identification (password protection)
Audit controls
Retention of off-site computer backups
Termination procedure
Data backup plan

Accepted Answer

The Answer of Administrative safeguard and Physical safeguard and Technical is...

Question 14

The clinical record process starts and ends with the _______,who plays a key role in protecting the dental practice from malpractice litigation.

Accepted Answer

A)  administrative assistant
B)  dentist
C)  hygienist
D)  expanded function assistant

Question 15

Noncompliance with statutes and regulations established by federal law can result in the dentist losing his/her dental license.

Accepted Answer

A) True 
 B)False

Question 16

Which of the following is the recommended spacing between progress note entries?

Accepted Answer

A)  There should be no space between progress note entries.
B)  Spacing between entries should be limited to one or two lines.
C)  Spacing between progress note entries should be limited to three lines.
D)  Ample spacing of approximately four lines should be left between progress note entries,to accommodate amendments to the original entry.

Question 17

Patients should be able to see the information in their clinical record.HIPAA regulations state that the office should provide access to the records or should provide a copy within 30 days of a written request.This is known as:

Accepted Answer

A)  Limits on Use of Personal Medical and Dental Information.
B)  Confidential Communications.
C)  Access to Clinical Records.
D)  Protected Health Information.

Question 18

Without a patient's written authorization,personal health information (PHI)cannot be shared with others for purposes unrelated to their healthcare.However,the Privacy Rule (HIPAA)mandates the disclosure of limited health information to satisfy specific public responsibilities.

Accepted Answer

A)  The first statement is true;the second statement is false.
B)  The first statement is false;the second statement is true.
C)  Both statements are true.
D)  Both statements are false.

Question 19

If a mistake is made in the clinical record,what procedure should be followed to make the correction?

Accepted Answer

A)  Replace the form and rewrite the information.
B)  Use "white-out" to cover the error,and rewrite the information over it.
C)  Cross it out so it is illegible,and write the error.
D)  Cross out the error with a single line,date and initial the error,and then write the correction information.

Question 20

Why is it important to document missed and broken appointments in the clinical record?

Accepted Answer

A)  So patients can be billed if they failed to give timely notice
B)  So a follow-up letter can be sent to explain the importance of continued treatment
C)  To document the intent of the dentist to complete work and follow-up in a timely manner
D)  To document that postoperative instructions are not being followed

Exam 8: Patient Clinical Records