Chapter 38 medical record test review

What information is contained in the medical record?

all of the above

Which of the following is not a function of the medical record?

to share information between members of the patient's family

The purpose of HIPAA is to

Provide patients with more control over the use and disclosure of their health information

The patient registration record consists of

Demographic and billing information

All of the following are included in the patient registration record except

allergies

Which of the following provides subjective data about a patient to assist the physician in arriving at a diagnosis?

health history

Which of the following is not included on a medication record for medication administered at the office?

Number of refills

A narrative report of an opinion about a patient's condition by a practitioner other than the attending physician is known as a

Consultation report

Which of the following services may be provided through home health care?

IV therapy, Respiratory care, Rehabilitation & Maternal-child care ANSWER ALL THE ABOVE

A report of the analysis of body specimens is known as a

laboratory report

All of the following are examples of diagnostic reports except

Urinalysis report

All of the following are examples of physical therapy except

Breathing treatments

Which of the following helps a patient with a disability learn new skills to perform the activities of daily living?

occupational therapy

What term is used to describe a patient who has been admitted to the hospital for at least one overnight stay?

inpatient

Conclusions drawn from an interpretation of data are known as

Medical impressions

All of the following are included in an operative report except

Prognosis

Which of the following reports consists of an account of the significant events of a patient's hospitalization?

Discharge summary report

Which of the following reports consists of a macroscopic and microscopic description of tissue removed during surgery?

Pathology report

A copy of the patient's emergency department report is sent to the

Patients family physician

A consent to treatment form is required for

Sebaceous cyst removal

Which of the following must be included in informed consent?

all of the above

When a medical assistant witnesses a patient's signature, it means that he or she

Verified the patients identity and watched the patient sign the form

Which of the following situations requires the completion of a release of medical information form?

When a patient transfers records to a new physician

All of the following are included on a release of medical information form except

medications being taken by the patient

Which of the following can be performed by an electronic medical record software program?

All of the above

All of the following are advantages of an electronic medical record (EMR) except

EMRs are exempt from the HIPAA regulations

How are paper documents entered into a patient's electronic medical record?

By scanning them into the computer

Which of the following are used to enter data into an electronic medical record?

Free-text entry, Drop-down lists, Check boxes ANSWER All of the above

In a source-oriented record, a radiology report is filed under which of the following chart dividers?

Lab/X-ray

With reverse chronological order, the most recent document is

Placed in front of the other documents

All of the following are included in the database section of a POR except

Plan of treatment

The acronym for the format used to organize POR progress notes is

soap

Data obtained from the patient are recorded in POR progress notes under

subjective data

The physician's interpretation of the patient's condition is recorded in POR progress notes under

Assessment

The purpose of the tab on a file folder is to

Identify the contents of the folder

All of the following assist in the collection of data for a health history except

Calling the patient "honey"

Which of the following can be used to enter a health history into an electronic medical record?

all of the above

The health history is taken

Before the physician performs the physical examination

What is the chief complaint?

The symptom causing the patient the most trouble

Which of the following questions should be used to elicit the chief complaint from a patient?

What seems to be the problem?

Which of the following is a correct example for recording the chief complaint?

burning in the chest and coughing for the past 2 days

An expansion of the chief complaint is known as the

present illness

What is the medical history?

The patient's previous diseases, injuries, and operations

All of the following are included in the medical history except

Occupation

A review of the health status of blood relatives is known as

family history

Which of the following is an example of a familial disease?

diabetes mellitus

The social history is important, because the following may affect the patient's condition:

Lifestyle

All of the following are included in the social history except

Chronic illnesses

What is the ROS?

A systematic review of each body system

What term is used to describe the process of making written entries about a patient in the medical record?

Charting

Black ink should be used when recording in the patient's chart to

Provide a permanent record

All of the following must be done when charting except

Include the patient's name at the beginning of each entry

A procedure should be charted immediately after being performed to

Avoid forgetting certain aspects of the procedure

Which of the following is the correct way to sign a charting entry?

D. Bennett, CMA (AAMA)

Why should a recording in the medical record never be erased or obliterated?

Credibility is reduced if the physician is involved in litigation

The purpose of progress notes is to

Update the medical record with new patient information

What is a symptom?

Any change in the body or its functioning that indicates disease

What is an objective symptom?

A symptom that can be observed by another person

Which of the following is an example of a subjective symptom?

pain

Laboratory tests ordered on a patient at an outside laboratory should be charted to provide documentation in case the following occurs:

The results are abnormal

Why is it important to document any instructions provided to the patient?

To protect the physician legally if the patient is harmed by not following the instructions

Flushed skin usually indicates

An elevated temperature

A yellow color of the skin that is first observed in the whites of the eyes is called

jaundice

A decrease in the amount of water in the body is known as

dehydration

What term is used to describe excessive perspiration?

diaphoresis

What term is used to describe dizziness?

vertigo