Question 1

If an employee of the practice records information inappropriately or inaccurately in a patient's chart, in a court of law, the ________ and the employee are held responsible.

Accepted Answer

The answer of If an employee of the practice records...

Question 2

The most appropriate way to terminate an initial interview with the patient is ____.

Accepted Answer

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?"F) A) and B)
G) A) and E)

Question 3

In the CHEDDAR format of documentation, the C section includes

Accepted Answer

A)   a list of current medications.
B)   consults.
C)   presenting problems.
D)   contributing information.
E)   assessment of the diagnostic process.F) C) and D)
G) D) and E)

Question 4

Objective or external factors that can be seen or felt by the physician or measured by an instrument are called ____.

Accepted Answer

A)   symptoms
B)   outcomes
C)   signs
D)   behavior
E)   feelingsF) A) and E)
G) C) and D)

Question 5

The specific information required of a population that must be obtained when a new patient makes an appointment with the office is ________.

Accepted Answer

The answer of The specific information required of a population...

Question 6

To reduce confusion in medical records, ________ are being used less often, except for those that are very clear in meaning.

Accepted Answer

The answer of To reduce confusion in medical records, ________...

Question 7

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.

Accepted Answer

The answer of A physical examination form that is used...

Question 8

The O section of SOAP documentation is ____.

Accepted Answer

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 optionsF) A) and D)
G) A) and C)

Question 9

When you document according to a numbered problem, the chart is arranged by the ________-oriented medical record system.

Accepted Answer

The answer of When you document according to a numbered...

Question 10

One of the most important duties of a medical assistant is to ____.

Accepted Answer

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 patientF) A) and B)
G) A) and C)

Question 11

The right to sign a release-of-records form for a child when the parents are divorced belongs to ____.

Accepted Answer

A)   the mother
B)   the father
C)   either the mother or the father
D)   the physician
E)   the court systemF) B) and E)
G) B) and D)

Question 12

In legal terms, medical records regarded as ____ may damage a physician's position in a lawsuit.

Accepted Answer

A)   convenient
B)   due course
C)   prompt
D)   responsible
E)   developmentF) C) and E)
G) A) and B)

Question 13

Subjective or internal conditions felt by the patient are ____.

Accepted Answer

A)   signs
B)   symptoms
C)   responses
D)   goals
E)   outcomesF) A) and B)
G) B) and D)

Question 14

The best place to interview a patient is ____.

Accepted Answer

A)   in the patient waiting room
B)   in a private room
C)   in the hallway leading to the exam rooms
D)   at the reception desk
E)   at any convenient locationF) B) and C)
G) C) and E)

Question 15

An example of a patient symptom is ____.

Accepted Answer

A)   pain
B)   high blood pressure
C)   swelling
D)   rash
E)   feverF) A) and D)
G) B) and C)

Question 16

Documenting a patient's walk down a hall as "fine" violates which "C" of charting?

Accepted Answer

A)   Completeness
B)   Clarity
C)   Conciseness
D)   Chronological order
E)   ConfidentialityF) B) and E)
G) None of the above

Question 17

Which of the following organizations reviews patient charts to monitor whether the care provided and the fee charged meet accepted standards?

Accepted Answer

A)   American Hospital Association
B)   American Medical Society
C)   American Medical Association
D)   Professional Board of Medical Examiners
E)   The Joint CommissionF) A) and B)
G) C) and D)

Question 18

The role the medical assistant plays in patient education is to explain ____.

Accepted Answer

A)   test results
B)   what treatment is appropriate
C)   the outcome of the disease
D)   management of the patient's condition as outlined by the physician
E)   how the patient should manage pain associated with the conditionF) D) and E)
G) None of the above

Question 19

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.

Accepted Answer

The answer of The section of a patient medical history...

Question 20

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.

Accepted Answer

The answer of When you release medical information, always send...

Exam 11: Medical Records and Documentation

Documenting a patient's walk down a hall as "fine" violates which "C" of charting?

Correct AnswerverifiedShow Answer

When you document according to a numbered problem, the chart is arranged by the ________-oriented medical record system.

Correct AnswerverifiedShow Answer

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.

Correct AnswerverifiedShow Answer

The O section of SOAP documentation is ____.

Correct AnswerverifiedShow Answer

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.

Correct AnswerverifiedShow Answer

In the CHEDDAR format of documentation, the C section includes

Correct AnswerverifiedShow Answer

The most appropriate way to terminate an initial interview with the patient is ____.

Correct AnswerverifiedShow Answer

In legal terms, medical records regarded as ____ may damage a physician's position in a lawsuit.

Correct AnswerverifiedShow Answer

If an employee of the practice records information inappropriately or inaccurately in a patient's chart, in a court of law, the ________ and the employee are held responsible.

Correct AnswerverifiedShow Answer

Subjective or internal conditions felt by the patient are ____.

Correct AnswerverifiedShow Answer

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.

Correct AnswerverifiedShow Answer

The specific information required of a population that must be obtained when a new patient makes an appointment with the office is ________.

Correct AnswerverifiedShow Answer

To reduce confusion in medical records, ________ are being used less often, except for those that are very clear in meaning.

Correct AnswerverifiedShow Answer

The role the medical assistant plays in patient education is to explain ____.

Correct AnswerverifiedShow Answer

Objective or external factors that can be seen or felt by the physician or measured by an instrument are called ____.

Correct AnswerverifiedShow Answer

The best place to interview a patient is ____.

Correct AnswerverifiedShow Answer

The right to sign a release-of-records form for a child when the parents are divorced belongs to ____.

Correct AnswerverifiedShow Answer

An example of a patient symptom is ____.

Correct AnswerverifiedShow Answer

One of the most important duties of a medical assistant is to ____.

Correct AnswerverifiedShow Answer

Which of the following organizations reviews patient charts to monitor whether the care provided and the fee charged meet accepted standards?

Correct AnswerverifiedShow Answer

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