Question 1

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

Accepted Answer

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

Question 2

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) A) and B)
G) All of the above

Question 3

When is it appropriate to send the original documents in a patient's health record?

Accepted Answer

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
E)   NeverF) B) and E)
G) A) and B)

Question 4

A guideline for releasing medical information is to ____.

Accepted Answer

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 facilitiesF) B) and E)
G) B) and C)

Question 5

The P section of SOAP documentation is ____.

Accepted Answer

A)   data provided by the patient
B)   data provided by test results
C)   the diagnosis or impression of the patient's problem
D)   the plan of action
E)   data provided by the physicianF) A) and D)
G) A) and C)

Question 6

Internal audits are done

Accepted Answer

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.F) B) and E)
G) C) and D)

Question 7

Medical records must be written neatly and legibly, contain up-to-date information, and present a(n) _______, professional record of a patient's case.

Accepted Answer

The answer of Medical records must be written neatly and...

Question 8

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.

Accepted Answer

The answer of Complete, thorough ________ ensures that the physician...

Question 9

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 C)

Question 10

A(n) ________ is an examination and review of patient records.

Accepted Answer

The answer of A(n) ________ is an examination and review...

Question 11

The first document found in a patient's financial record is the ____.

Accepted Answer

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 formF) B) and C)
G) None of the above

Question 12

In conventional or ________-oriented medical records, patient information is arranged according to who supplied the data.

Accepted Answer

The answer of In conventional or ________-oriented medical records, patient...

Question 13

The A section of SOAP documentation includes ____.

Accepted Answer

A)   the diagnosis of impression of a patient's problem
B)   data that comes from examination results and from the physician
C)   the plan of action
D)   data from the patient
E)   a description of treatment optionsF) B) and C)
G) A) and E)

Question 14

Part of creating timely and accurate records is maintaining a(n) ________ tone in your writing.

Accepted Answer

The answer of Part of creating timely and accurate records...

Question 15

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 D)
G) B) and E)

Question 16

A(n) ________audit is frequently done by a third party if fraudulent billing is suspected.

Accepted Answer

The answer of A(n) ________audit is frequently done by a...

Question 17

When you are in doubt about who is ________ to give consent to release information, you should ask your supervisor before releasing confidential medical records.

Accepted Answer

The answer of When you are in doubt about who...

Question 18

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.

Accepted Answer

The answer of You should make a(n) ________ to medical...

Question 19

Recording information in the medical record is called ____.

Accepted Answer

A)   transcription
B)   description
C)   dictation
D)   filing
E)   documentationF) None of the above
G) A) and C)

Question 20

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 ____.

Accepted Answer

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 patientF) B) and C)
G) B) and E)

Exam 11: Medical Records and Documentation

A guideline for releasing medical information is to ____.

Correct AnswerverifiedShow Answer

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.

Correct AnswerverifiedShow Answer

Recording information in the medical record is called ____.

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

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 ____.

Correct AnswerverifiedShow Answer

When is it appropriate to send the original documents in a patient's health record?

Correct AnswerverifiedShow Answer

The P section of SOAP documentation is ____.

Correct AnswerverifiedShow Answer

Internal audits are done

Correct AnswerverifiedShow Answer

When you are in doubt about who is ________ to give consent to release information, you should ask your supervisor before releasing confidential medical records.

Correct AnswerverifiedShow Answer

The first document found in a patient's financial record is the ____.

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

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.

Correct AnswerverifiedShow Answer

A(n) ________ is an examination and review of patient records.

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

A(n) ________audit is frequently done by a third party if fraudulent billing is suspected.

Correct AnswerverifiedShow Answer

Medical records must be written neatly and legibly, contain up-to-date information, and present a(n) _______, professional record of a patient's case.

Correct AnswerverifiedShow Answer

The A section of SOAP documentation includes ____.

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

In conventional or ________-oriented medical records, patient information is arranged according to who supplied the data.

Correct AnswerverifiedShow Answer

Part of creating timely and accurate records is maintaining a(n) ________ tone in your writing.

Correct AnswerverifiedShow Answer

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