CHAPTER 38 – MEDICAL RECORD MC &CHAPTER 42 – SCHEDULING MC

1. What information is contained in the medical record?

A. Health history
B. Results of the physical examination
C. Laboratory reports
D. Progress notes
E. All of these

✅ Correct Answer: E — All of these

💡 Explanation:
A medical record includes ALL patient-related information: history, exams, labs, and progress notes.

🔥 Example:
A patient chart includes vitals, lab results, and SOAP notes → all are part of the record.

2. Which of the following is NOT a function of the medical record?

A. To provide information for making decisions regarding the patient’s care
B. To document the patient’s progress
C. To serve as a legal document
D. To share information between members of the patient’s family

✅ Correct Answer: D — To share information between members of the patient’s family

💡 Explanation:
Medical records are confidential and protected by HIPAA.

🔥 Example:
You cannot tell a patient’s family about their condition without permission.

3. What is the purpose of the HIPAA Privacy Rule?

A. Reduce exposure of patients to bloodborne pathogens
B. Provide patients with more control over the use and disclosure of their health information
C. Prevent the patient’s records from being copied
D. Encourage the patient to become more involved in preventive health care

✅ Correct Answer: B — Provide patients with more control over the use and disclosure of their health information

💡 Explanation:
HIPAA protects patient privacy and controls who can access health information.

🔥 Example:
Patients must sign a release form before records are shared.

4. What is included in the patient registration record?

A. Demographic and billing information
B. Medication instructions given to the patient
C. The results of the physical examination
D. A list of problems associated with the patient’s illness
E. All of these

✅ Correct Answer: A — Demographic and billing information

💡 Explanation:
Registration records include basic info like name, DOB, insurance, and billing.

🔥 Example:
Front desk collects insurance and address → registration record.

5. Which of the following demographic data were introduced as part of the patient registration record in order to qualify for Medicare incentive payments?

A. Siblings
B. Ethnicity
C. Current employer
D. Birth place

✅ Correct Answer: B — Ethnicity

💡 Explanation:
HITECH/MACRA required collecting ethnicity data for healthcare reporting.

🔥 Example:
Patient forms now ask race/ethnicity.

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

A. Laboratory tests
B. Physical examination
C. Health history
D. Diagnostic tests

✅ Correct Answer: C — Health history

💡 Explanation:
Subjective data = what the patient says → health history.

🔥 Example:
“I feel dizzy” → subjective → helps diagnosis.

7. Which of the following is included on an immunization record that may not be included on an ordinary record for medication administered at the office?

A. Name of the medication
B. Route of administration
C. Dosage administered
D. Manufacturer and lot number
E. All of these

✅ Correct Answer: D — Manufacturer and lot number

💡 Explanation:
Vaccines must track manufacturer + lot for safety tracking.

🔥 Example:
If a vaccine batch is recalled, patients can be identified.

8. What is a narrative report of an opinion about a patient’s condition by a practitioner other than the attending provider called?

A. Correspondence report
B. Discharge summary report
C. Consultation report
D. Health history report

✅ Correct Answer: C — Consultation report

💡 Explanation:
A specialist gives an opinion → consultation report.

🔥 Example:
Cardiologist reviews patient → writes consult report.

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

A. IV therapy
B. Respiratory therapy
C. Rehabilitation
D. Maternal-child care
E. All of these

✅ Correct Answer: E — All of these

💡 Explanation:
Home health includes many services.

🔥 Example:
Patient receives IV antibiotics at home.

10. What type of report contains the results of the analysis of body specimens?

A. Therapeutic report
B. Diagnostic report
C. Laboratory report
D. Progress report

✅ Correct Answer: C — Laboratory report

💡 Explanation:
Lab reports show test results from samples.

🔥 Example:
Blood test results = lab report.

11. Which of the following is NOT an example of a report of a diagnostic procedure?

A. Urinalysis report
B. Spirometry report
C. Electrocardiogram report
D. Radiology report

✅ Correct Answer: A — Urinalysis report

💡 Explanation:
Urinalysis is a lab test, not a diagnostic procedure report.

🔥 Example:
EKG = diagnostic, urinalysis = lab.

12. Which of the following is a physical therapy service?

A. Activities of daily living
B. Hydrotherapy
C. Dressing change
D. Breathing treatment

✅ Correct Answer: B — Hydrotherapy

💡 Explanation:
Hydrotherapy is a physical therapy treatment.

🔥 Example:
Water-based rehab exercises.

13. Which of the following helps a patient with a disability learn new ways to perform skills such as dressing or cooking?

A. Speech therapy
B. Occupational therapy
C. Physical therapy
D. Dietitian

✅ Correct Answer: B — Occupational therapy

💡 Explanation:
OT helps with daily living skills.

🔥 Example:
Teaching a patient how to dress after injury.

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

A. Outpatient
B. Ambulatory patient
C. Guest
D. Inpatient

✅ Correct Answer: D — Inpatient

💡 Explanation:
Inpatient = stays overnight.

🔥 Example:
Surgery patient admitted → inpatient.

15. What term might be used before there is enough information to make a definitive diagnosis?

A. Medical impression
B. Prognosis
C. Symptom
D. Physical examination

✅ Correct Answer: A — Medical impression

💡 Explanation:
A preliminary diagnosis is called a medical impression.

🔥 Example:
“Possible infection” before labs confirmed.

16. Which of the following describes a surgical procedure?

A. Consent form
B. Operative report
C. Discharge summary
D. Emergency department report

✅ Correct Answer: B — Operative report

💡 Explanation:
An operative report documents details of a surgical procedure.

🔥 Example:
After surgery, the surgeon writes what was done → operative report.

17. Which of the following reports consists of an account of the significant events of a patient’s hospitalization?

A. Emergency department report
B. Pathology report
C. History and physical report
D. Discharge summary report

✅ Correct Answer: D — Discharge summary report

💡 Explanation:
Summarizes the patient’s entire hospital stay.

🔥 Example:
Includes diagnosis, treatment, and follow-up instructions.

18. What federal act requires that medical offices ask for information regarding ethnicity, race, and preferred language?

A. MACRA
B. HITECH
C. HIPAA
D. None of these

✅ Correct Answer: B — HITECH

💡 Explanation:
HITECH promotes EHR use and requires demographic data collection.

🔥 Example:
Forms ask race/ethnicity for reporting.

19. Who receives a copy of the patient’s emergency department report?

A. Patient’s insurance company
B. Patient
C. Patient’s primary care provider
D. Laboratory

✅ Correct Answer: C — Patient’s primary care provider

💡 Explanation:
Ensures continuity of care.

🔥 Example:
ER sends report to primary doctor.

20. What procedure requires a consent to treatment form?

A. Tuberculin skin testing
B. Sebaceous cyst removal
C. Ear irrigation
D. Blood pressure measurement

✅ Correct Answer: B — Sebaceous cyst removal

💡 Explanation:
Invasive procedures require consent.

🔥 Example:
Minor surgery → needs informed consent.

21. Which of the following must be included in procedure consent?

A. Explanation of risks
B. Alternative treatments
C. Prognosis
D. Purpose of procedure
E. All of these

✅ Correct Answer: E — All of these

💡 Explanation:
Informed consent includes risks, benefits, alternatives, and purpose.

🔥 Example:
Doctor explains surgery risks + options before signing.

22. What does it mean when a medical assistant witnesses a patient’s signature?

A. Verified identity and saw the patient sign
B. The information is correct
C. Patient understands risks
D. Provider explained consent

✅ Correct Answer: A — Verified identity and saw the patient sign

💡 Explanation:
MA only witnesses signature, not explains procedure.

🔥 Example:
MA watches patient sign form → signs as witness.

23. Which situation requires a release of medical information form?

A. Transferring records to a new provider
B. Billing insurance
C. Seeing another provider in same office
D. Determining insurance eligibility

✅ Correct Answer: A — Transferring the patient’s records to a new provider

💡 Explanation:
Records cannot be shared without authorization.

🔥 Example:
Patient switches doctor → needs release form.

24. Which of the following is NOT included on a release of medical information form?

A. Specific information to release
B. Need for information
C. Patient’s signature
D. Expiration date
E. Medications being taken

✅ Correct Answer: E — Medications being taken

💡 Explanation:
Form includes authorization details, not medical data.

🔥 Example:
Release form = permission, not patient history.

25. Which can be performed by an electronic health record (EHR) system?

A. Creation of record
B. Storage
C. Editing
D. Retrieval
E. All of these

✅ Correct Answer: E — All of these

💡 Explanation:
EHR systems manage all aspects of records.

🔥 Example:
Doctors create, update, and view records digitally.

26. In a source-oriented record, a radiology report is filed under which division?

A. History and physical
B. Progress notes
C. Lab/x-ray
D. Hospital

✅ Correct Answer: C — Lab/x-ray

💡 Explanation:
SOR organizes records by data type.

🔥 Example:
X-rays go under lab/imaging section.

27. With reverse chronological order, how is the most recent document filed?

A. Alphabetically
B. By subject
C. Placed in front
D. Placed in back

✅ Correct Answer: C — Placed in front

💡 Explanation:
Newest documents go first.

🔥 Example:
Latest visit note is on top.

✅ Correct Answer: C — Placed in front

💡 Explanation:
Newest documents go first.

🔥 Example:
Latest visit note is on top.

✅ Correct Answer: D — Plan of treatment

💡 Explanation:
Database = collected data, not treatment plans.

🔥 Example:
Plan comes AFTER assessment.

29. The acronym for organizing POMR progress notes is:

A. SOAP
B. TGIF
C. OSHA
D. PPR

✅ Correct Answer: A — SOAP

💡 Explanation:
SOAP = Subjective, Objective, Assessment, Plan.

🔥 Example:
Used in progress notes daily.

30. Where are data obtained from the patient recorded in POMR notes?

A. Subjective
B. Objective
C. Assessment
D. Plan

✅ Correct Answer: A — Subjective

💡 Explanation:
Patient-reported info = subjective.

🔥 Example:
“I feel dizzy” → subjective.

31. What is the provider’s interpretation of the patient’s condition recorded under in POR progress notes?

A. Subjective data
B. Objective data
C. Assessment
D. Plan

✅ Correct Answer: C — Assessment

💡 Explanation:
Assessment = provider’s diagnosis or interpretation of the data.

🔥 Example:
“Possible pneumonia” → provider’s interpretation → assessment.

32. What format is used most often for paper-based records?

A. POR
B. SOR
C. Either POR or SOR can be used
D. Neither POR nor SOR

✅ Correct Answer: C — Either POR or SOR can be used

💡 Explanation:
Both formats are acceptable for paper records.

🔥 Example:
Clinics may choose either structure.

✅ Correct Answer: C — Either POR or SOR can be used

💡 Explanation:
Both formats are acceptable for paper records.

🔥 Example:
Clinics may choose either structure.

✅ Correct Answer: D — Calling the patient “honey”

💡 Explanation:
Unprofessional language can damage rapport.

🔥 Example:
Always address patients respectfully (Mr./Ms.).

34. Which can be used to enter a health history into an electronic health record?

A. Patient fills paper form scanned in
B. MA enters info while asking questions
C. Patient completes it on computer
D. All of these

✅ Correct Answer: D — All of these

💡 Explanation:
EHR allows multiple data entry methods.

🔥 Example:
Tablet intake forms or MA interview.

35. When is the health history taken?

A. After physical exam
B. After lab results
C. Before physical exam
D. After diagnosis

✅ Correct Answer: C — Before the provider performs the physical examination

💡 Explanation:
History guides the physical exam.

🔥 Example:
Patient explains symptoms → doctor examines.

36. What is the chief complaint?

A. Probable outcome
B. Symptom causing most trouble
C. Detailed description using medical terms
D. Tentative diagnosis

✅ Correct Answer: B — The symptom causing the patient the most trouble

💡 Explanation:
Chief complaint = main reason for visit.

🔥 Example:
“I have chest pain” → CC.

37. Which question should be used to elicit the chief complaint?

A. Where does it hurt?
B. Are you sick?
C. How long have you been ill?
D. What seems to be the problem?
E. All of these

✅ Correct Answer: D — What seems to be the problem?

💡 Explanation:
Open-ended question gets main complaint.

🔥 Example:
Patient explains symptoms freely.

38. Which is a correct example for recording the chief complaint?

A. Complains of pain in left shoulder
B. The patient does not feel well today
C. “Burning in the chest and coughing for 2 days.”
D. Otitis media following a cold

✅ Correct Answer: C — “Burning in the chest and coughing for 2 days.”

💡 Explanation:
Chief complaint should be in patient’s words (quotes).

🔥 Example:
“I feel dizzy” → correct format.

39. What is the past medical history?

A. Previous diseases, injuries, operations
B. Current symptom
C. Lifestyle info
D. Family diseases

✅ Correct Answer: A — The patient’s previous diseases, injuries, and operations

💡 Explanation:
PMH = past conditions.

🔥 Example:
History of asthma or surgery.

40. Which is NOT included in the medical history?

A. Accidents/injuries
B. Immunizations
C. Operations
D. Medications
E. Occupation

✅ Correct Answer: E — Occupation

💡 Explanation:
Occupation belongs in social history, not medical history.

🔥 Example:
Construction worker → social history.

41. What is the name for the review of health status of blood relatives?

A. Family history
B. Review of systems
C. Genetic review
D. Chronologic history

✅ Correct Answer: A — Family history

💡 Explanation:
Focuses on hereditary diseases.

🔥 Example:
Father has diabetes.

42. Which is an example of a familial disease?

A. Tuberculosis
B. Pneumonia
C. Diabetes mellitus
D. Emphysema

✅ Correct Answer: C — Diabetes mellitus

💡 Explanation:
Diabetes can run in families.

🔥 Example:
Multiple relatives with diabetes.

43. Which is NOT included in the social history?

A. Dietary history
B. Health habits
C. Occupation
D. Chronic illnesses

✅ Correct Answer: D — Chronic illnesses

💡 Explanation:
Chronic illnesses = PMH, not social history.

🔥 Example:
Smoking = social, diabetes = PMH.

44. What is the review of systems (ROS)?

A. Past diseases
B. Chief complaint
C. Systematic questions about each body system
D. Family diseases

✅ Correct Answer: C — Systematic questions about each body system

💡 Explanation:
ROS checks all systems for symptoms.

🔥 Example:
“Any headaches? Chest pain? Nausea?”

45. What term describes making entries in a medical record?

A. Entering
B. Registering
C. Putting in data
D. Documenting

✅ Correct Answer: D — Documenting

💡 Explanation:
Documenting = recording patient information.

🔥 Example:
Writing SOAP notes.

46. Why should a procedure be documented immediately after being performed?

A. Avoid documenting out of sequence
B. Avoid performing wrong procedure
C. Avoid forgetting aspects of the procedure
D. Prevent another staff member from documenting

✅ Correct Answer: C — It avoids forgetting certain aspects of the procedure

💡 Explanation:
Delays can lead to missing or inaccurate details.

🔥 Example:
Forgetting medication dosage if not charted right away.

47. What is the purpose of progress notes?

A. Review of body systems
B. Update record with new info
C. Prevent condition worsening
D. Ensure follow-up

✅ Correct Answer: B — To update the medical record with new patient information

💡 Explanation:
Progress notes track changes over time.

🔥 Example:
Daily updates on patient condition.

48. What is a symptom?

A. Interpretation of data
B. Change in body indicating disease
C. Outcome of disease
D. Scientific method

✅ Correct Answer: B — Any change in the body or its functioning that indicates disease

💡 Explanation:
Symptoms are subjective (felt by patient).

🔥 Example:
“I feel dizzy.”

49. Why should laboratory tests from outside labs be documented?

A. If patient skips test
B. If results abnormal
C. If condition worsens
D. If results negative

✅ Correct Answer: B — In case the test results are abnormal

💡 Explanation:
Important for diagnosis and follow-up.

🔥 Example:
Abnormal blood test → requires action.

50. Why is it important to document patient instructions?

A. Ensure understanding
B. Legal protection
C. Ensure compliance
D. Insurance record

✅ Correct Answer: B — To protect the provider legally if the patient is harmed by not following instructions

💡 Explanation:
Documentation proves instructions were given.

🔥 Example:
Patient ignores advice → provider protected.

51. What time interval is frequently used to set up appointment schedules?

A. 5 min
B. 15 min
C. 30 min
D. 45 min

✅ Correct Answer: B — 15 minutes

💡 Explanation:
Standard scheduling interval.

🔥 Example:
Most clinics use 15-min slots.

52. What scheduling type groups similar conditions?

A. Wave
B. Clustering
C. Modified wave
D. Stream

✅ Correct Answer: B — Clustering

💡 Explanation:
Groups similar patients together.

🔥 Example:
All physicals in one block.

53. Which system schedules multiple patients at once and sees them in order?

A. Wave
B. Clustering
C. Modified wave
D. Stream

✅ Correct Answer: A — Wave

💡 Explanation:
Multiple patients scheduled same time.

🔥 Example:
3 patients at 9:00 → seen in order.

54. What is the goal of stream scheduling?

A. Equal time per patient
B. Always someone waiting
C. Time for calls
D. Steady patient flow

✅ Correct Answer: D — Steady flow of patients

💡 Explanation:
Minimizes wait time and gaps.

🔥 Example:
Continuous patient movement.

55. Minimum time for new patient exam?

A. 10 min
B. 15 min
C. 20 min
D. 30 min

✅ Correct Answer: D — 30 minutes

💡 Explanation:
New patients need more time.

🔥 Example:
History + exam = longer visit.

56. Advantage of open booking?

A. More flexibility
B. Reduce wait time
C. Computer use
D. Predict wait time

✅ Correct Answer: A — More flexibility

💡 Explanation:
Patients come without set time.

🔥 Example:
Walk-in clinic style.

57. When is double-booking used?

A. Two rooms
B. Acute illness
C. Multiple providers
D. Running behind

✅ Correct Answer: B — Acute illness must be fit in

💡 Explanation:
Urgent cases added to schedule.

🔥 Example:
Chest pain patient added immediately.

58. Example of modified wave scheduling?

A. Two per slot
B. Specific times
C. No times
D. First half scheduled, second open

✅ Correct Answer: D — First half scheduled, second open

💡 Explanation:
Allows catch-up time.

🔥 Example:
Busy first half, flexible second.

59. How does MA set up schedule?

A. Block patient times
B. Block MA unavailable
C. Block provider unavailable
D. Block office open

✅ Correct Answer: C — Block provider unavailable times

💡 Explanation:
Schedule built around provider.

🔥 Example:
Doctor lunch = blocked.

60. How far in advance can appointments be scheduled?

A. 3 months
B. 6 months
C. 12 months
D. 2 years

✅ Correct Answer: B — Up to 6 months

💡 Explanation:
Standard scheduling window.

🔥 Example:
Routine visits booked months ahead.

61. Which visit takes the most time?

A. Immunization
B. Post-op
C. Complete physical
D. Follow-up

✅ Correct Answer: C — Complete physical examination

💡 Explanation:
Most comprehensive visit.

🔥 Example:
Full exam + history.

62. Who is an established patient?

A. No exam needed
B. Regular visits
C. Insurance referral
D. Seen within 3 years

✅ Correct Answer: D — Seen within past 3 years

💡 Explanation:
Definition of established patient.

🔥 Example:
Seen last year → established.

63. Fasting lab scheduling?

A. Week before
B. Morning
C. Full bladder
D. Any time

✅ Correct Answer: B — Schedule early morning

💡 Explanation:
Fasting easier overnight.

🔥 Example:
No food after midnight → morning test.

64. Highest priority patient?

A. Nausea 3 days
B. Fever 101.8°F
C. Weight loss
D. Sleep issue

✅ Correct Answer: B — Fever of 101.8°F

💡 Explanation:
Fever may indicate serious infection.

🔥 Example:
Needs same-day evaluation.

65. Lowest priority condition?

A. Pregnancy bleeding
B. Diarrhea >2 days
C. Cold/runny nose
D. Bleeding cut

✅ Correct Answer: C — Cold with runny nose

💡 Explanation:
Non-urgent condition.

🔥 Example:
Can wait 1–2 days.

66. Handling pharma reps?

A. Give appointment
B. Take card/contact later
C. Wait between patients
D. End of day

✅ Correct Answer: B — Take their cards and inform provider

💡 Explanation:
Doesn’t disrupt patient care.

🔥 Example:
Provider decides later.

67. Unscheduled non-urgent patient?

A. Fit in
B. End of day
C. Wait for cancellation
D. Appointment only

✅ Correct Answer: D — Give next available appointment

💡 Explanation:
Maintains schedule order.

🔥 Example:
Not urgent → schedule properly.

68. Missed appointment action?

A. Send letter
B. Provider calls
C. Document
D. Ignore

✅ Correct Answer: C — Document missed appointment

💡 Explanation:
Legal record required.

🔥 Example:
“No-show” recorded in chart.

69. Why document missed appointments?

A. Show missed visit
B. Legal defense
C. Terminate relationship
D. Shows noncompliance
E. All of these

✅ Correct Answer: E — All of these

💡 Explanation:
Protects provider legally and clinically.

🔥 Example:
Patient misses multiple visits → documented.

70. How handle patient always late?

A. Last appointment
B. New provider
C. Reminder call
D. Note

✅ Correct Answer: A — Give last appointment of the day

💡 Explanation:
Prevents disruption.

🔥 Example:
Late patient doesn’t delay others.

71. Info needed before scheduling diagnostic procedure?

A. Name/phone
B. Insurance
C. Procedure type
D. Diagnosis
E. All of these

✅ Correct Answer: E — All of these

💡 Explanation:
Complete info ensures proper scheduling.

🔥 Example:
MRI needs diagnosis + insurance.

72. What info is needed when scheduling surgery?

A. Authorization number
B. Date
C. Next of kin
D. Living will
E. All of these

✅ Correct Answer: E — All of these

💡 Explanation:
Surgery scheduling requires full details.

🔥 Example:
Insurance + consent + contacts all needed.