Question 1

The concise account of the patient's symptoms in his or her own words is the __________.

Accepted Answer

chief complaint
The concise account of the patient's symptoms in his or her own words is the chief complaint.

Question 2

Subjective information is that which the physician observes during the physical examination of the patient.

Accepted Answer

A) True 
 B)False

Question 3

When preparing a file for a new patient, the medical assistant should:

Accepted Answer

A)  make sure the patient's name is spelled correctly
B)  review the forms the patient filled out for completeness
C)  copy the insurance card or make sure that insurance information is included
D)  all of the aboveE) A) and B)
F) A) and C)

Question 4

A(n) __________ schedule is a plan for keeping and purging medical records.

Accepted Answer

retention
A retention schedule...

Question 5

HIPAA recommends that physicians keep the records on patients for at least:

Accepted Answer

A)  1 year
B)  2 years
C)  3 years
D)  HIPAA does not recommend a number of years.E) A) and B)
F) A) and C)

Question 6

The three stages of machine transcription do not include:

Accepted Answer

A)  keyboarding the dictated text to a printed document
B)  reviewing the dictated text with the patient
C)  dictating into a dictation unit
D)  listening to what has been dictatedE) A) and B)
F) B) and D)

Question 7

The most efficient type of medical record is the:

Accepted Answer

A)  computer-based medical record
B)  paper-based medical record
C)  both are equally efficient
D)  neither is efficientE) A) and D)
F) A) and C)

Question 8

Entities considered essential or necessary are called __________.

Accepted Answer

requisites
Requisites are nece...

Question 9

Transcription tasks might be outsourced to:

Accepted Answer

A)  individuals working at home
B)  a business that offers transcription services
C)  a hospital employee who does extra transcription work
D)  any of the aboveE) A) and C)
F) A) and B)

Question 10

A folder used to provide space for the temporary filing of materials is a(n) __________.

Accepted Answer

OUTfolder
The OUTfol...

Question 11

Which statement is not accurate about correcting charting errors?

Accepted Answer

A)  Insert the correction above or immediately after the error.
B)  Draw two clear lines through the error.
C)  In the margin, initial and date the error correction.
D)  Do not hide charting errors.E) A) and B)
F) B) and D)

Question 12

The method of filing in which one report is laid on top of the older report, resembling a roof, is called:

Accepted Answer

A)  alphanumeric filing
B)  gleaning
C)  shingling
D)  pressboard filingE) A) and B)
F) B) and C)

Question 13

The newest component used today to complete transcription and authenticate records is __________ software.

Accepted Answer

A)  voice-activated
B)  voice recognition
C)  voice registry
D)  voice-controlledE) None of the above
F) C) and D)

Question 14

Continuity of care means :

Accepted Answer

A)  an aggregate of activities designed to ensure adequate quality, especially in manufactured products or in the service industries
B)  a formal examination of an organization's or individual's accounts
C)  medical attention that continues smoothly from one provider to another so that the patient receives the most benefit
D)  granted or endowed with a particular authorityE) B) and C)
F) A) and D)

Question 15

The process of moving an active file to inactive status is called:

Accepted Answer

A)  purging
B)  indexing
C)  coding
D)  conditioningE) B) and D)
F) A) and B) A

Question 16

Which of the following are not needed when describing a patient's chief complaint?

Accepted Answer

A)  Remedies the patient has tried to relieve symptoms
B)  The duration of pain
C)  The time when symptoms were first noticed
D)  How many family members are healthyE) B) and C)
F) A) and D)

Question 17

An informed consent form must address which of the following?

Accepted Answer

A)  Risks and benefits of the procedure
B)  Reasonable alternatives to the procedure
C)  Risks and benefits of not performing the procedure
D)  All of the aboveE) A) and D)
F) C) and D)

Question 18

__________ of an entry in a medical record is never acceptable.

Accepted Answer

Obliteration
Obliteration is the marking out of an entry and is never acceptable in the medical record.

Question 19

Which of the following is not a method of organizing a medical record?

Accepted Answer

A)  Source oriented
B)  Problem oriented
C)  Progressively
D)  ChronologicallyE) None of the above
F) A) and B)

Question 20

The physical medical record belongs to the:

Accepted Answer

A)  patient
B)  physician or provider
C)  insurance company
D)  all of the aboveE) C) and D)
F) B) and D)

Exam 14: The Paper Medical Record Formerly Medical Records Management

The concise account of the patient's symptoms in his or her own words is the __________.

Correct Answerverifiedchief complaint The concise account of the patient's symptoms in his or her own words is the chief complaint.

Subjective information is that which the physician observes during the physical examination of the patient.

Correct AnswerverifiedShow Answer

When preparing a file for a new patient, the medical assistant should:

Correct AnswerverifiedShow Answer

A(n) __________ schedule is a plan for keeping and purging medical records.

Correct AnswerverifiedretentionA retention schedule...View AnswerShow Answer

HIPAA recommends that physicians keep the records on patients for at least:

Correct AnswerverifiedShow Answer

The three stages of machine transcription do not include:

Correct AnswerverifiedShow Answer

The most efficient type of medical record is the:

Correct AnswerverifiedShow Answer

Entities considered essential or necessary are called __________.

Correct AnswerverifiedrequisitesRequisites are nece...View AnswerShow Answer

Transcription tasks might be outsourced to:

Correct AnswerverifiedShow Answer

A folder used to provide space for the temporary filing of materials is a(n) __________.

Correct AnswerverifiedOUTfolderThe OUTfol...View AnswerShow Answer

Which statement is not accurate about correcting charting errors?

Correct AnswerverifiedShow Answer

The method of filing in which one report is laid on top of the older report, resembling a roof, is called:

Correct AnswerverifiedShow Answer

The newest component used today to complete transcription and authenticate records is __________ software.

Correct AnswerverifiedShow Answer

Continuity of care means :

Correct AnswerverifiedShow Answer

The process of moving an active file to inactive status is called:

Correct AnswerverifiedA

Which of the following are not needed when describing a patient's chief complaint?

Correct AnswerverifiedShow Answer

An informed consent form must address which of the following?

Correct AnswerverifiedShow Answer

__________ of an entry in a medical record is never acceptable.

Correct AnswerverifiedObliteration Obliteration is the marking out of an entry and is never acceptable in the medical record.

Which of the following is not a method of organizing a medical record?

Correct AnswerverifiedShow Answer

The physical medical record belongs to the:

Correct AnswerverifiedShow Answer

Correct Answer
verified
chief complaint The concise account of the patient's symptoms in his or her own words is the chief complaint.

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified
retention
A retention schedule...
View Answer

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified
requisites
Requisites are nece...
View Answer

Correct Answer
verified

Correct Answer
verified
OUTfolder
The OUTfol...
View Answer

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified
A

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified
Obliteration Obliteration is the marking out of an entry and is never acceptable in the medical record.

Correct Answer
verified

Correct Answer
verified