Question 1

Information corrected or added some time after a patient's visit can be regarded as ____.

Accepted Answer

A)   substituting
B)   convenient
C)   due course
D)   omission
E)   sequencingF) A) and D)
G) All of the above

Question 2

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

Accepted Answer

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

Question 3

Patient records are used in medical research ____.

Accepted Answer

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 insuranceF) A) and B)
G) B) and E)

Question 4

In addition to being essential documents for patient care management, patient records are used for ____.

Accepted Answer

A)   advertising physician services
B)   providing patient education
C)   evaluating patient satisfaction
D)   showing results to other patients
E)   evaluating public recordsF) A) and B)
G) B) and D)

Question 5

The type of documentation that provides an orderly series of steps for dealing with any medical case is ____.

Accepted Answer

A)   charting by exception
B)   SOAP
C)   source recording
D)   focus charting
E)   daily chartingF) B) and E)
G) B) and C)

Question 6

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) A) and E)
G) A) and C)

Question 7

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) C) and D)
G) B) and E)

Question 8

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 ____.

Accepted Answer

A)   due course
B)   transcription
C)   convenient
D)   development
E)   sequencingF) B) and C)
G) All of the above

Question 9

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

Question 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 ____.

Accepted Answer

A)   patient medical history
B)   physician examination form
C)   patient registration form
D)   laboratory results
E)   hospital discharge summaryF) B) and E)
G) A) and B)

Question 11

Patient records, also known as ________, contain important information about a patient's medical history and present condition and serve as communication tools as well as legal documents.

Accepted Answer

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Question 12

Audits that are done by medical staff before patient billing is submitted are ____.

Accepted Answer

A)   prospective internal audits
B)   retrospective external audits
C)   introspective internal audits
D)   retrospective internal audits
E)   prospective external auditsF) A) and E)
G) A) and D)

Question 13

What color ink is preferred for handwritten documentation in a patient's medical record?

Accepted Answer

A)   Blue
B)   Black
C)   Red
D)   Purple
E)   BrownF) A) and B)
G) D) and E)

Question 14

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?

Accepted Answer

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 sheetF) A) and D)
G) All of the above

Question 15

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) A) and D)
G) A) and E)

Exam 11: Medical Records and Documentation

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

Correct Answer
verified

Patient records are used in medical research ____.

Correct Answer
verified

The A section of SOAP documentation includes ____.

Correct Answer
verified

Patient records, also known as ________, contain important information about a patient's medical history and present condition and serve as communication tools as well as legal documents.

Correct Answer
verified
chartsheal...
View Answer

Audits that are done by medical staff before patient billing is submitted are ____.

Correct Answer
verified

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 ____.

Correct Answer
verified

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 ____.

Correct Answer
verified

In addition to being essential documents for patient care management, patient records are used for ____.

Correct Answer
verified

Information corrected or added some time after a patient's visit can be regarded as ____.

Correct Answer
verified

The type of documentation that provides an orderly series of steps for dealing with any medical case is ____.

Correct Answer
verified

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 Answer
verified

What color ink is preferred for handwritten documentation in a patient's medical record?

Correct Answer
verified

Correct Answer
verified

A guideline for releasing medical information is to ____.

Correct Answer
verified

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

Correct Answer
verified

Exam 11: Medical Records and Documentation

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

Correct AnswerverifiedShow Answer

Patient records are used in medical research ____.

Correct AnswerverifiedShow Answer

The A section of SOAP documentation includes ____.

Correct AnswerverifiedShow Answer

Patient records, also known as ________, contain important information about a patient's medical history and present condition and serve as communication tools as well as legal documents.

Correct Answerverifiedchartsheal...View AnswerShow Answer

Audits that are done by medical staff before patient billing is submitted are ____.

Correct AnswerverifiedShow Answer

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 ____.

Correct AnswerverifiedShow Answer

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 ____.

Correct AnswerverifiedShow Answer

In addition to being essential documents for patient care management, patient records are used for ____.

Correct AnswerverifiedShow Answer

Information corrected or added some time after a patient's visit can be regarded as ____.

Correct AnswerverifiedShow Answer

The type of documentation that provides an orderly series of steps for dealing with any medical case is ____.

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

What color ink is preferred for handwritten documentation in a patient's medical record?

Correct AnswerverifiedShow Answer

Correct AnswerverifiedShow Answer

A guideline for releasing medical information is to ____.

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified
chartsheal...
View Answer

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
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Correct Answer
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Correct Answer
verified

Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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