Question 1

Who may accept a subpoena?

Accepted Answer

A)  The prospective witness 
B)  An authorized person 
C)  Both a and b 
D)  Neither a nor b

Question 2

When a patient fails to return for needed treatment, documentation should be made

Accepted Answer

A)  in the patient's medical record. 
B)  in the appointment book. 
C)  on the financial record or ledger card. 
D)  all of the above.

Question 3

An inventory of body systems obtained through a series of questions that are used to identify signs and/or symptoms of the patient is known as a/an ____________________.

Accepted Answer

The answer of An inventory of body systems obtained through...

Question 4

Match each of these terms, as they are used in a medical office, with the correct definition.

-When the pain/symptom occurs

Accepted Answer

A) Location 
B) Quality 
C) Severity 
D) Duration 
E) Timing
F)Context
G)Modifying factors
H)Associated signs and symptoms.

Question 5

Medications which are prescribed and being taken by the patient should be listed in the health record, specifying frequency and ______________.

Accepted Answer

The answer of Medications which are prescribed and being taken...

Question 6

If you are in doubt about the documentation in any health record, to obtain the most specific and accurate terminology, you should ______________ the physician.

Accepted Answer

The answer of If you are in doubt about the...

Question 7

Match each of these terms, as they are used in a medical office, with the correct definition.

-Situation associated with the pain/symptom.

Accepted Answer

A) Location 
B) Quality 
C) Severity 
D) Duration 
E) Timing
F)Context
G)Modifying factors
H)Associated signs and symptoms

Question 8

The four levels of physical examination are referred to as problem focused, expanded problem focused, ____________, and comprehensive.

Accepted Answer

The answer of The four levels of physical examination are...

Question 9

For a complete ROS, at least _____ organ systems must be reviewed and documented.

Accepted Answer

The answer of For a complete ROS, at least _____...

Question 10

The word chronic should be used instead of recurrent for a medical condition that persists over a long period.

Accepted Answer

A) True 
 B)False

Question 11

Match each of these terms, as they are used in a medical office, with the correct definition.

-Area of the body in which the symptom is occurring.

Accepted Answer

A) Location 
B) Quality 
C) Severity 
D) Duration 
E) Timing
F)Context
G)Modifying factors
H)Associated signs and symptoms

Question 12

Match these types of physicians with the description of the services each provides.

-Provider whose opinion is requested by another physician about evaluation and management of a specific problem.

Accepted Answer

A) Attending physician 
B) Consulting physician 
C) Ordering physician 
D) Referring physician 
E) Treating or performing physician

Question 13

Written information documenting facts and events that were rendered as patient care is referred to as a _____________________.

Accepted Answer

The answer of Written information documenting facts and events that...

Question 14

Repair of lacerations that require layered closure of one or more of the deeper layers of the skin and tissues is known as

Accepted Answer

A)  simple. 
B)  complex. 
C)  intermediate. 
D)  cosmetic.

Question 15

A statement describing symptoms and problems as a reason for the office visit is known as the patient's ____________________.

Accepted Answer

The answer of A statement describing symptoms and problems as...

Question 16

Incentive programs for adoption of EHR will transition into ______________ for those who do not adopt HER over the next several years in the form of adjustments.

Accepted Answer

The answer of Incentive programs for adoption of EHR will...

Question 17

Reasons for documentation include

Accepted Answer

A)  defense of a professional liability claim. 
B)  insurance carriers require accurate documentation that supports procedure and diagnostic codes. 
C)  both a and b 
D)  none of the above.

Question 18

A reference list of all staff members' names, job titles, signatures, and initials is known as a/an ____________________.

Accepted Answer

The answer of A reference list of all staff members'...

Question 19

Match each of these types of medical services to the correct definition.

-Providing treatment for a patient and subsequent referral by the treating physician to another physician for treatment of the same condition.

Accepted Answer

A) Concurrent care 
B) Consultation 
C) Continuity of care 
D) Counseling 
E) Critical care
F)Emergency
G)Referral

Question 20

Most insurance companies perform routine ____________________ on practices with unusual billing patterns or excessive payment amounts.

Accepted Answer

The answer of Most insurance companies perform routine ____________________ on...

Exam 4: Medical Documentation and the Electronic Health Record

Who may accept a subpoena?

When a patient fails to return for needed treatment, documentation should be made

An inventory of body systems obtained through a series of questions that are used to identify signs and/or symptoms of the patient is known as a/an ____________________.

Match each of these terms, as they are used in a medical office, with the correct definition. -When the pain/symptom occurs

Medications which are prescribed and being taken by the patient should be listed in the health record, specifying frequency and ______________.

If you are in doubt about the documentation in any health record, to obtain the most specific and accurate terminology, you should ______________ the physician.

Match each of these terms, as they are used in a medical office, with the correct definition. -Situation associated with the pain/symptom.

The four levels of physical examination are referred to as problem focused, expanded problem focused, ____________, and comprehensive.

For a complete ROS, at least _____ organ systems must be reviewed and documented.

The word chronic should be used instead of recurrent for a medical condition that persists over a long period.

Match each of these terms, as they are used in a medical office, with the correct definition. -Area of the body in which the symptom is occurring.

Match these types of physicians with the description of the services each provides. -Provider whose opinion is requested by another physician about evaluation and management of a specific problem.

Written information documenting facts and events that were rendered as patient care is referred to as a _____________________.

Repair of lacerations that require layered closure of one or more of the deeper layers of the skin and tissues is known as

A statement describing symptoms and problems as a reason for the office visit is known as the patient's ____________________.

Incentive programs for adoption of EHR will transition into ______________ for those who do not adopt HER over the next several years in the form of adjustments.

Reasons for documentation include

A reference list of all staff members' names, job titles, signatures, and initials is known as a/an ____________________.

Match each of these types of medical services to the correct definition. -Providing treatment for a patient and subsequent referral by the treating physician to another physician for treatment of the same condition.

Most insurance companies perform routine ____________________ on practices with unusual billing patterns or excessive payment amounts.