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Which of the following is NOT included in the patient registration record?


A) Date of birth
B) Allergies
C) Employer
D) Patient's insurance company

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Which of the following can be performed by an electronic medical record software program?


A) Creation of a medical record
B) Storage of a medical record
C) Editing of a medical record
D) Retrieval of a medical record
E) All of the above

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The health history is taken


A) After the physician performs the physical examination
B) After laboratory test results are reviewed
C) Before the physician performs the physical examination
D) After the physician makes a diagnosis of the patient's condition

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The purpose of the tab on a file folder is to


A) Hold documents in place in the folder
B) Identify the contents of the folder
C) Prevent the folder from being misfiled
D) Keep the folder closed when not in use

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Which of the following is NOT a function of the medical record?


A) To provide information for making decisions regarding the patient's care
B) To document the patient's progress
C) To serve as a legal document
D) To share information between members of the patient's family

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Which of the following does NOT assist in the collection of data for a health history?


A) A quiet, comfortable room
B) Showing interest in the patient
C) Showing concern for the patient
D) Calling the patient "honey"

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The acronym for the format used to organize POR progress notes is


A) SOAP
B) TGIF
C) OSHA
D) PPR

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A decrease in the amount of water in the body is known as


A) Edema
B) Acidosis
C) Epistaxis
D) Dehydration

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A procedure should be charted immediately after being performed to


A) Avoid charting the procedure out of sequence
B) Avoid performing the wrong procedure on a patient
C) Avoid forgetting certain aspects of the procedure
D) Prevent another staff member from charting the procedure

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Which of the following reports consists of an account of the significant events of a patient's hospitalization?


A) Emergency department report
B) Pathology report
C) History and physical report
D) Discharge summary report

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Data obtained from the patient are recorded in POR progress notes under


A) Subjective data
B) Objective data
C) Assessment
D) Plan

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What term is used to describe excessive perspiration?


A) Dehydration
B) Diaphoresis
C) Edema
D) Hyperemesis

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What term is used to describe dizziness?


A) Epistaxis
B) Vertigo
C) Urticaria
D) Pruritus

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Discuss all levels of governmental legislation and regulation as they apply to medical assisting practice, including FDA and DEA regulations

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Answered by ExamLex AI

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Medical assisting practice is subject to...

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Which of the following situations requires the completion of a release of medical information form?


A) When a patient transfers records to a new physician
B) To bill the patient's insurance company
C) To send the patient's records to a consulting physician
D) To determine the patient's eligibility for insurance benefits

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Why should a recording in the medical record never be erased or obliterated?


A) It makes it harder to read the chart.
B) The patient may not receive the proper care.
C) Credibility is reduced if the physician is involved in litigation.
D) It indicates the procedure was performed incorrectly.

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Which of the following provides subjective data about a patient to assist the physician in arriving at a diagnosis?


A) Laboratory tests
B) Physical examination
C) Health history
D) Diagnostic tests

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Which of the following questions should be used to elicit the chief complaint from a patient?


A) Where does it hurt?
B) Are you sick?
C) How long have you been ill?
D) What seems to be the problem?
E) All of the above

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What information is contained in the medical record?


A) Health history
B) Results of the physical examination
C) Laboratory reports
D) Progress notes
E) All of the above

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