Chapter 11
Medical Records and Documentation
Multiple Choice Questions
1. | One of the most important duties of a medical assistant is to ____.
A. | point out to the patient how test results have changed |
B. | review patient charts to monitor the care provided |
C. | fill out and maintain accurate and thorough patient records |
D. | explain how the patient's general health has improved or lessened |
E. | tell the physician what is wrong with the patient |
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2. | Important information about a patient's medical history and present condition is found in the ____.
A. | patient’s health record |
B. | problem-oriented medical record system |
D. | medical office record book |
E. | scheduling or appointment book |
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3. | In addition to being essential documents for patient care management, patient records are used for ____.
A. | advertising physician services |
B. | providing patient education |
C. | evaluating patient satisfaction |
D. | showing results to other patients |
E. | evaluating public records |
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4. | The role the medical assistant plays in patient education is to explain ____.
B. | what treatment is appropriate |
C. | the outcome of the disease |
D. | management of the patient’s condition as outlined by the practitioner |
E. | how the patient should manage pain associated with the condition |
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5. | Which of the following organizations reviews patient health records to monitor whether the care provided and the fee charged met accepted standards?
A. | American Hospital Association |
B. | American Medical Society |
C. | American Medical Association |
D. | Professional Board of Medical Examiners |
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6. | Patient records are used in medical research ____.
A. | for data regarding patient responses and side effects |
B. | only occasionally, because it is usually considered illegal |
C. | for experimentation with treatment that has not yet been approved |
D. | as a means to get research money |
E. | to determine the average amount being paid for health insurance |
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7. | Which of the following information is found on the patient registration form?
B. | Use of alcohol or drugs |
C. | Laboratory results from another physician |
D. | Name of the person to contact in an emergency |
E. | Social and occupational history |
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8. | A patient’s illness and the reason for a visit to the medical office are found in the ____.
B. | patient registration form |
C. | records from other healthcare providers |
E. | patient medical history |
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9. | The purpose of having a patient sign an informed consent form is to ensure that the ____.
A. | patient has a legal recourse against the physician |
B. | patient understands the treatment offered and the possible outcomes |
C. | physician may terminate care at any time |
D. | physician does not have to document every visit |
E. | physician can delegate the patient's care to the medical assistant |
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10. | A summary of the reason a patient entered the hospital, the care the patient received in the hospital, and the outcome of the hospitalization is found in the ____.
A. | patient medical history |
B. | physician examination form |
C. | patient registration form |
E. | hospital discharge summary |
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11. | The first document found in a patient's financial record is the ____.
A. | patient registration form |
B. | doctor's diagnosis and treatment plan |
C. | patient medical history |
D. | records from other physicians or hospitals |
E. | signed informed consent form |
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12. | The best way to make sure the licensed practitioner sees a patient’s X-ray report before filing it is to _____.
A. | tell the nurse to tell the practitioner the results |
B. | place the results on the practitioner’s desk |
C. | give the report to another practitioner in the office to give to the practitioner |
D. | have the practitioner initial the report |
E. | ask the patient to give the report to the practitioner |
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13. | The most appropriate way to terminate an initial interview with the patient is ____.
A. | "The doctor will be in shortly." |
B. | "Is there anything else you would like the doctor to know?" |
C. | "I need to terminate this interview." |
D. | "The lab technician will be in to draw blood." |
E. | "Are you sure you haven't forgotten to tell me anything?" |
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14. | Dr. Girardi tries to call a patient to explain test results, but the patient does not answer the phone, and Dr. Girardi does not leave a message because he prefers to discuss the results with the patient. As the medical assistant, it is your job to ____.
A. | remind the physician to call again later |
B. | leave the physician a note to call again |
C. | record and date the call in the patient record |
D. | attempt to call and relay the physician's message later |
E. | attempt to call and leave a message for the patient |
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15. | The best place to interview a patient is ____.
A. | in the patient waiting room |
C. | in the hallway leading to the exam rooms |
E. | at any convenient location |
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16. | "The patient got out of bed and walked 20 feet without reporting or displaying signs of shortness of breath" is an example of ____ in documentation.
C. | breach of confidentiality |
D. | using the client's words |
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17. | Documenting a patient's walk down a hall as "fine" violates which "C" of charting?
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18. | An example of a patient sign is ____.
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19. | An example of a patient symptom is ____.
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20. | Objective or external factors that can be seen or felt by the practitioner or measured by an instrument are called ____.
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21. | Subjective or internal conditions felt by the patient are ____.
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22. | The type of documentation that provides an orderly series of steps for dealing with any medical case is ____.
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23. | The S section of SOAP documentation is ____.
A. | data that comes directly from the patient |
B. | the diagnosis or impression of a patient's problem |
D. | data that comes from the physician or test results |
E. | a description of treatment options |
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24. | The O section of SOAP documentation is ____.
A. | the plan of action, including follow-up |
B. | data that comes from examination results and from the physician |
C. | data that comes from the patient |
D. | the diagnosis or impression of a patient's problem |
E. | a description of treatment options |
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25. | The A section of SOAP documentation includes ____.
A. | the diagnosis of impression of a patient's problem |
B. | data that comes from examination results and from the physician |
E. | a description of treatment options |
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26. | The P section of SOAP documentation is ____.
A. | data provided by the patient |
B. | data provided by test results |
C. | the diagnosis or impression of the patient's problem |
E. | data provided by the physician |
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27. | All information should be entered in the record at the time of a patient's visit, not days, weeks, or months later. This is called ____.
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28. | In legal terms, medical records regarded as ____ may damage a physician's position in a lawsuit.
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29. | Which of the following is necessary to release a patient's record to the patient's insurance company?
A. | Physician's permission |
B. | Patient's written consent |
C. | Patient's verbal consent |
D. | Either the patient's consent or the physician's release |
E. | Verification of the insurance company |
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30. | A guideline for releasing medical information is to ____.
A. | have the patient give a verbal consent |
B. | send the original documents |
C. | fax all confidential materials |
D. | call the recipient to confirm that all materials were received |
E. | release all the patient's records, including those from other facilities |
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31. | When is it appropriate to send the original documents in a patient’s health record?
A. | When the record is subpoenaed for a court case |
B. | When the record is going to another physician |
C. | When the patient signs an authorization to release them |
D. | When the insurance company specifically requests them |
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32. | The reason a patient's record should not be sent by fax machine is that ____.
A. | copies from a fax machine are difficult to read |
B. | there is no way to tell who will see the document |
C. | it takes too long to fax each page |
D. | fax machines are unreliable |
E. | the digital transmission from a fax machine can be corrupted |
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33. | The right to sign a release-of-records form for a child when the parents are divorced belongs to ____.
C. | either the mother or the father |
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34. | When do most states consider children to be adults with the right to privacy?
E. | When the child has a job |
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35. | The appropriate way to delete information on a medical record is to ____.
A. | draw a line through the original information so it is still legible |
B. | use correction fluid to cover it up |
C. | erase the mistaken data |
D. | scratch out the incorrect information |
E. | retype the entire record, leaving out the information to be deleted |
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36. | Which of the following is appropriate when correcting a medical record?
A. | Black out the incorrect information |
B. | Place a note near the correction stating why it was made |
C. | Type the correct information over the incorrect data |
D. | Write the date and your initials at the end of the medical record |
E. | Erase the incorrect information and enter the new information |
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37. | A medical record received from another health provider should be ___.
A. | entered into the patient's chart |
B. | placed in a file in the medical office |
C. | given to the patient to keep |
D. | kept in the physician's office for reference |
E. | shredded to maintain confidentiality |
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38. | Recording information in the medical record is called ____.
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39. | In the problem-oriented medical record (POMR), which of the following includes a record of the patient's history, information from the initial interview, and any tests?
A. | Educational, diagnostic, and treatment plan |
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40. | Internal audits are done
A. | by agencies from outside the medical practice. |
B. | by the federal government. |
C. | by medical staff on random records. |
D. | to catch medical errors. |
E. | at a patient's request. |
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41. | Audits that are done by medical staff before patient billing is submitted are ____.
A. | prospective internal audits |
B. | retrospective external audits |
C. | introspective internal audits |
D. | retrospective internal audits |
E. | prospective external audits |
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42. | In which section of the CHEDDAR format of documentation can the diagnosis be found?
A. | Details of problems and complaints |
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43. | In the CHEDDAR format of documentation, the C section includes
A. | a list of current medications. |
D. | contributing information. |
E. | assessment of the diagnostic process. |
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44. | What color ink is preferred for handwritten documentation in a patient's medical record?
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45. | When should you record exam and test results?
A. | Every Friday afternoon |
E. | As soon as they are available |
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46. | Benise is a new medical assistant in the clinic. She has little experience, but she has a great attitude and she is determined to do the job correctly. As you pass by, you notice that she is frowning at a patient's medical record. You ask if you can help, and she tells you that the patient has moved across town to take a new job, so all of his address, phone number, employment, and health insurance have changed. Benise is trying to figure out how to make all of those changes to the record. "It just won't fit!" she exclaims. What advice might you offer to Benise?
A. | Use correction fluid to cover the old information to make space for the new information |
B. | Make a note on the patient's registration to "see the updated registration sheet" |
C. | Use as many abbreviations as necessary to make all of the new information fit |
D. | Shred the old registration sheet and create an entirely new one |
E. | Write as small as possible and continue sentences on the back of the sheet |
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47. | Kenneth is preparing copies of X-ray and lab results from Mrs. Vendel's chart to be mailed to another physician's office. He tells you that he thinks this is a waste of time, but Mrs. Vendel called and requested that the records be sent to the other physician's office for a second opinion. How should you respond?
A. | "If she likes the second opinion, we may lose Mrs. Vendel's business." |
B. | "It's a good thing she called in person so that she could authorize the transfer." |
C. | "Mrs. Vendel is infamous for wanting second opinions; we do this all the time." |
D. | "I'm not busy right now; do you want any help copying the records?" |
E. | "Has Mrs. Vendel signed a written consent to have the records transferred?" |
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Fill in the Blank Questions
48. | Information in the medical record provides a plan to follow for the ________ of patient care.
________________________________________ |
49. | The medical assistant is responsible to the ________ and the physician for both the medical and administrative procedures performed and the accurate recording of those procedures.
________________________________________ |
50. | If an employee of the practice records information inappropriately or inaccurately in a patient’s health record, legally the ________ and the employee are held responsible.
________________________________________ |
51. | The patient ________ form contains legal, financial, and demographic information about the patient.
________________________________________ |
52. | The informed ________ form verifies that a patient understands the treatment offered and the possible outcomes or side effects of treatment.
________________________________________ |
53. | The ________ summary form generally includes a summary of the reason the patient entered the hospital; tests, procedures, or operations performed in the hospital; medications administered in the hospital; and the disposition or outcome of the case.
________________________________________ |
54. | Complete, thorough ________ ensures that the physician will have detailed notes about each contact with the patient and about the treatment plan, patient responses and progress, and treatment outcomes.
________________________________________ |
55. | In conventional or ________-oriented medical records, patient information is arranged according to who supplied the data.
________________________________________ |
56. | When you document according to a numbered problem, the chart is arranged by the ________-oriented medical record system.
________________________________________ |
57. | Whether the medical practice uses conventional or POMR charts, you can use the ________ approach to documentation.
________________________________________ |
58. | Medical records must be written neatly and legibly, contain up-to-date information, and present a(n) _______, professional record of a patient's case.
________________________________________ |
59. | You should make a(n) ________ to medical records in a way that does not suggest any intention to deceive, cover up, alter, or add information to conceal a lack of proper medical care.
________________________________________ |
60. | To reduce confusion in medical records, ________ are being used less often, except for those that are very clear in meaning.
________________________________________ |
61. | All health records are considered the property of the licensed practitioner or the medical facility; however, the information they contain belongs to the patient and is regarded as ________. The patient’s written consent is required to release them.
________________________________________ |
62. | When you are in doubt about who is ________ to give consent to release information, you should ask your supervisor before releasing confidential medical records.
________________________________________ |
63. | A(n) ________ is an examination and review of patient records.
________________________________________ |
64. | A(n) ________audit is frequently done by a third party if fraudulent billing is suspected.
________________________________________ |
65. | A physical examination form that is used during an "oral examination" to identify any signs or symptoms the patient may be experiencing or reveal information about an illness or condition is called a review of _________ or ROS.
________________________________________ |
66. | The section of a patient medical history form that contains the patient's description of the current condition or complaint is called the _________of present illness section.
________________________________________ |
67. | Part of creating timely and accurate records is maintaining a(n) ________ tone in your writing.
________________________________________ |
68. | Patient X-ray and lab tests should be placed in the medical record according to facility policy, but always in reverse ________ order.
________________________________________ |
69. | When you release medical information, always send ________ unless the record will be used in a court case, in which case you should send the original records.
________________________________________ |
70. | The specific information required of a population that must be obtained when a new patient makes an appointment with the office is ________.
________________________________________ |
71. | The primary problem for which a patient comes to see the physician is known as the ________ complaint.
________________________________________ |
Multiple Choice Questions
72. | Information such as laboratory results that are required quickly are commonly sent to the medical facility by which method?
E. | Telling the physician what is wrong with the patient |
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73. | What does the A in SOAP documentation stand for?
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Fill in the Blank Questions
74. | Everything that is entered into the patient’s health record by the medical assistant must be dated and ___________.
________________________________________ |
75. | The Notice of _______________ is a written document that provides patients with information on how their personal health information is used and protected.
________________________________________ |