Question 1

Typing or writing verbal words is known as
A. transcription
B. dictation
C. telecommunicating
D. faxing
E. transferring

Accepted Answer

transcription

Question 2

Information recorded in a patient chart is called:
A. triage.
B. documentation.
C. initiation.
D. examination.
E. compliance.

Accepted Answer

documentation.

Question 3

Transforming spoken notes into accurate form is referred to as:
A. transferring.
B. faxing.
C. dictation.
D. transcription.

Accepted Answer

transcription.

Question 4

Which of the following are included in a patient's medical record?
□ billing history
□ occupation
□ medical history
□ address and phone number
□ favorite color

Accepted Answer

occupation;
medical history;
address and phone number

Question 5

Which of the following are the roles of patient records?
□ public education
□ legal documents
□ employment
□ communication tools
□ research

Accepted Answer

legal documents;
communication tools;
research

Question 6

The process of recording information in a medical record is called
A. notation
B. record keeping
C. addendum
D. documentation

Accepted Answer

documentation

Question 7

What can patient health records be used for?
A. criticize patients about their conditions
B. remind patients about their prescription refills
C. educate patients about their own condition and treatment plans
D. notify patients about upcoming appointments

Accepted Answer

educate patients about their own condition and treatment plans

Question 8

Laboratory and other test results may come from which of the following sources?
□ in office
□ insurance companies
□ independent laboratories
□ pharmaceutical representative
□ hospitals

Accepted Answer

in office;
independent laboratories;
hospitals

Question 9

Which statements are considered acceptable in a patient medical record?
□ the patient appears sore
□ the patient seems uncomfortable
□ the patient is unsteady
□ the patient appears to be upset
□ the patient has a red rash

Accepted Answer

the patient is unsteady;
the patient has a red rash

Question 10

Continuation of a medical record lasts as long as
A. the patient consents to having the record maintained
B. until the practice closes
C. the patient's insurance coverage lasts
D. the patient is under the doctor's care

Accepted Answer

the patient is under the doctor's care

Question 11

Advising a patient of the possible outcomes or side effects of the treatment offered is known as
A. implied consent
B. informed consent
C. full disclosure
D. legal counseling

Accepted Answer

informed consent

Question 12

Which of the following applies to correspondence with or about a patient?
□ Each piece should be scanned into the computer
□ A copy of each piece should be sent to the patient
□ Each piece should be stamped with the date received
□ Each piece should be kept in the patient's medical record

Accepted Answer

Each piece should be stamped with the date received;
Each piece should be kept in the patient's medical record

Question 13

How are tests results from outside the practice best organized?
A. In a section of the record designated for results
B. In a separate record
C. Combined with all registration information
D. Results from outside sources are not contained in the record.

Accepted Answer

In a section of the record designated for results

Question 14

Where is the diagnosis and treatment plan recorded for every patient?
A. medical history form
B. consent form
C. progress note
D. referral note

Accepted Answer

progress note

Question 15

Which approach to documentation provides an orderly series of steps for dealing with any medical case?
A. POMR
B. Systematic documentation
C. SOAP
D. Conventional, or Source-oriented, Record

Accepted Answer

SOAP

Question 16

Which format of medical records documentation breaks the SOAP format into smaller components?
A. Conventional
B. Source-oriented
C. CHEDDAR
D. PHI

Accepted Answer

CHEDDAR

Question 17

A form that verifies that a patient understands the offered treatment and its possible outcomes or side effects is called a(n)
A. patient registration form
B. hospital discharge summary
C. patient intake form
D. informed consent form

Accepted Answer

informed consent form

Question 18

For which reasons is blue the preferred ink color for written documentation?
□ blue ink is easily confused with a photocopy
□ blue ink is easier to cover with correction fluid
□ blue ink is difficult to match
□ blue ink will copy as black

Accepted Answer

blue ink is difficult to match;
blue ink will copy as black

Question 19

Information corrected or added improperly after a patient's visit can be regarded legally as 
A. inconvenient
B. convenient
C. appropriate
D. accurate

Accepted Answer

convenient

Question 20

In the CHEDDAR format of medical documentation, the "C" stands for
A. chief complaint
B. consultation
C. claim
D. clinical

Accepted Answer

chief complaint

Question 21

What should be done if there is not enough room near the error to make a correction?
A. use white out over the error and write the correction on top of it
B. make the correction on a post-it note and place it on top of the error
C. write the correction as a line item at the back of the chart
D. make a notation near the error as to where the correction may be found

Accepted Answer

make a notation near the error as to where the correction may be found

Question 22

How many Cs are there to charting?
A. 4
B. 5
C. 10
D. 6

Accepted Answer

6

Question 23

Which of the following help keep handwritten entries neat and easy to find?
□ writing in pencil so that corrections are easy to make
□ using blue or black ink
□ making sure handwriting is legible
□ using a good-quality pen

Accepted Answer

using blue or black ink;
making sure handwriting is legible;
using a good-quality pen

Question 24

To ensure a professional attitude and tone, which of the following pieces of information should be recorded in medical records?
□ opinions or speculations about a patient's problems
□ laboratory or test results
□ patient's chief complaint in the patient's own words
□ physician's observations
□ your personal, subjective comments

Accepted Answer

laboratory or test results;
patient's chief complaint in the patient's own words;
physician's observations

Question 25

Individuals who are under the age of 18 and living on their own or are married, parents, or in the armed services are considered
A. minors
B. adults
C. emancipated minors
D. late adolescents

Accepted Answer

emancipated minors

Question 26

Which of the following means to examine and review a group of patient records for completeness and accuracy?
A. audit
B. compliance
C. evaluation
D. review

Accepted Answer

audit

Question 27

Which of the following is a guideline that should be followed when releasing medical information?
A. obtain verbal consent from the patient to release the information
B. file a signed and dated authorization in the patient's medical record
C. send information originating from sources outside your facility
D. always sent the original material

Accepted Answer

file a signed and dated authorization in the patient's medical record

Question 28

Which materials may be used in creating a new patient paper medical record?
□ fax machine
□ file folders
□ hole punch
□ labels
□ forms
□ telephone

Accepted Answer

file folders;
hole punch;
labels;
forms

Question 29

Measurable data, such as test results, that are documented in the chart are called:
A. assessment data.
B. None of these are correct.
C. objective data.
D. subjective data.
E. plan data.

Accepted Answer

objective data.

Question 30

A patient's medical history includes:
A. All of these are correct.
B. occupational history.
C. current medications.
D. social history.
E. family history.

Accepted Answer

All of these are correct.

Question 31

Which of the following would not be included on a patient registration form?
A. Date of birth
B. Allergies
C. Insurance
D. Current address
E. Occupation

Accepted Answer

Allergies

Question 32

A patient's symptom is what type of data?
A. None of these are correct
B. Subjective data
C. Plan data
D. Objective data
E. Assessment data

Accepted Answer

Subjective data

Question 33

What is the approved medical abbreviation for family history?
A. fl
B. ft
C. fx
D. FH
E. fr

Accepted Answer

FH

Question 34

When documenting information in a patient chart by problem, this is called:
A. OSHA.
B. HIPAA.
C. POMR.
D. CLIA.
E. SOAP.

Accepted Answer

POMR

Question 35

A valid release of information:
A. None of these are correct.
B. can be written or verbal.
C. can be verbal.
D. is not necessary.
E. is written.

Accepted Answer

is written.

Question 36

Which of the following items does not require documentation in the patient chart?
A. All of these must be documented
B. Telephone calls
C. Consultation reports
D. Prescription refills
E. Patient follow-up report

Accepted Answer

All of these must be documented

Question 37

To help prove that a physician gave appropriate and proper care to a patient:
A. all contacts with the patient should be documented in the chart.
B. errors should be corrected appropriately.
C. abnormal labs should not be filed in the patient's chart
D. document all patient contact and correct all errors.

Accepted Answer

document all patient contact and correct all errors.

Question 38

Which of the following record types may be corrected or updated?
A. Patient medical history
B. Provider written notes
C. Lab reports
D. All of these
E. Medical assistant’s written notes

Accepted Answer

All of these

Question 39

Which of the following should not be kept in a patient's medical record?
A. Diagnosis and treatment plans
B. Results of laboratory tests
C. Financial information regarding payments
D. Medical history
E. Correspondence about the patient

Accepted Answer

Financial information regarding payments

Question 40

If a patient brings in test results from another physician, the MA should:
A. throw them out because you will do your own tests.
B. keep them with the chart and document the information.
C. keep them with the chart.
D. document the information in the chart.

Accepted Answer

keep them with the chart and document the information.

Question 41

Medical records that are compiled according to the originator of the data are called:
A. alphabetical medical records.
B. OSHA.
C. SOAP.
D. problem-oriented medical records.
E. source-oriented medical records.

Accepted Answer

source-oriented medical records.

Question 42

A patient's history of present illness includes:
A. current medications.
B. onset of disease.
C. severity of disease.
D. severity and onset of disease.

Accepted Answer

severity and onset of disease.

Question 43

Informed consent forms are used:
A. None of these are correct.
B. for physical examination results.
C. to allow a medical assistant to take a patient history.
D. to record receipt of records from previous physicians.
E. to verify that a patient understands treatment options.

Accepted Answer

to verify that a patient understands treatment options.

Question 44

Forms that advise the patient on treatment options, risks of procedures, and voluntary participation are called:
A. informed consent forms.
B. demographic forms.
C. authorization forms.
D. medication knowledge forms.

Accepted Answer

informed consent forms.

Question 45

Which of the following would not be included on a medical history form?
A. History of heart murmurs
B. Insurance information
C. Problems with asthma
D. Allergies

Accepted Answer

Insurance information

Question 46

Which of the following is not a C of charting?
A. Compliant
B. Client's words
C. Chronological order
D. Conciseness
E. Clarity

Accepted Answer

Compliant

Question 47

If a child lives with his mother who is divorced from his father, the ____ may sign the release of information.
A. mother
B. father
C. child
D. None of these are correct
E. mother and father

Accepted Answer

mother and father

Question 48

The actual medical record belongs to the:
A. patient.
B. lawyer.
C. board of directors.
D. insurance company.
E. practice.

Accepted Answer

practice.

Question 49

Which of the following cannot be released by a medical office?
A. Reports from other physicians
B. Any information in a patient's chart can be released.
C. Surgical reports
D. Lab reports
E. Dictated notes older than five years

Accepted Answer

Reports from other physicians

Question 50

The information in the chart serves to assist in:
A. noncompliance
B. continuity of care.
C. patient education.
D. patient registration.
E. quality of treatment.

Accepted Answer

continuity of care.

Question 51

Which of the following should not be included when documenting in a patient’s medical record?
A. Date and time of service
B. Lab results
C. Physician’s plan of care
D. The patient’s own words
E. Personal opinions or thoughts

Accepted Answer

Personal opinions or thoughts

Question 52

To correct any entry in a medical record, which of the following is true?
A. Fully obliterate the original entry.
B. Draw a single line through the error, initial and date, then make the correction.
C. Enter the corrected information directly over the original entry.
D. The provider must sign off on all corrections.
E. White-out may be used.

Accepted Answer

Draw a single line through the error, initial and date, then make the correction.

Question 53

Which of the following issues is not as much of an issue with dictated/transcribed records?
A. Accuracy
B. Completeness
C. All of these
D. Neatness/legibility
E. Timeliness

Accepted Answer

Neatness/legibility

MED254 MED OFF PRO 2

MED254 CH 11 MEDICAL RECORDS AND DOCUMENTATION

Question	Answer
MED254 CH 11 MEDICAL RECORDS & DOCUMENTATION
Typing or writing verbal words is known as A. transcription B. dictation C. telecommunicating D. faxing E. transferring	transcription
Information recorded in a patient chart is called: A. triage. B. documentation. C. initiation. D. examination. E. compliance.	documentation.
Transforming spoken notes into accurate form is referred to as: A. transferring. B. faxing. C. dictation. D. transcription.	transcription.
Which of the following are included in a patient's medical record? □ billing history □ occupation □ medical history □ address and phone number □ favorite color	occupation; medical history; address and phone number
Which of the following are the roles of patient records? □ public education □ legal documents □ employment □ communication tools □ research	legal documents; communication tools; research
The process of recording information in a medical record is called A. notation B. record keeping C. addendum D. documentation	documentation
What can patient health records be used for? A. criticize patients about their conditions B. remind patients about their prescription refills C. educate patients about their own condition and treatment plans D. notify patients about upcoming appointments	educate patients about their own condition and treatment plans
Laboratory and other test results may come from which of the following sources? □ in office □ insurance companies □ independent laboratories □ pharmaceutical representative □ hospitals	in office; independent laboratories; hospitals
Which statements are considered acceptable in a patient medical record? □ the patient appears sore □ the patient seems uncomfortable □ the patient is unsteady □ the patient appears to be upset □ the patient has a red rash	the patient is unsteady; the patient has a red rash
Continuation of a medical record lasts as long as A. the patient consents to having the record maintained B. until the practice closes C. the patient's insurance coverage lasts D. the patient is under the doctor's care	the patient is under the doctor's care
Advising a patient of the possible outcomes or side effects of the treatment offered is known as A. implied consent B. informed consent C. full disclosure D. legal counseling	informed consent
Which of the following applies to correspondence with or about a patient? □ Each piece should be scanned into the computer □ A copy of each piece should be sent to the patient □ Each piece should be stamped with the date received □ Each piece should be kept in the patient's medical record	Each piece should be stamped with the date received; Each piece should be kept in the patient's medical record
How are tests results from outside the practice best organized? A. In a section of the record designated for results B. In a separate record C. Combined with all registration information D. Results from outside sources are not contained in the record.	In a section of the record designated for results
Where is the diagnosis and treatment plan recorded for every patient? A. medical history form B. consent form C. progress note D. referral note	progress note
Which approach to documentation provides an orderly series of steps for dealing with any medical case? A. POMR B. Systematic documentation C. SOAP D. Conventional, or Source-oriented, Record	SOAP
Which format of medical records documentation breaks the SOAP format into smaller components? A. Conventional B. Source-oriented C. CHEDDAR D. PHI	CHEDDAR
A form that verifies that a patient understands the offered treatment and its possible outcomes or side effects is called a(n) A. patient registration form B. hospital discharge summary C. patient intake form D. informed consent form	informed consent form
For which reasons is blue the preferred ink color for written documentation? □ blue ink is easily confused with a photocopy □ blue ink is easier to cover with correction fluid □ blue ink is difficult to match □ blue ink will copy as black	blue ink is difficult to match; blue ink will copy as black
Information corrected or added improperly after a patient's visit can be regarded legally as A. inconvenient B. convenient C. appropriate D. accurate	convenient
In the CHEDDAR format of medical documentation, the "C" stands for A. chief complaint B. consultation C. claim D. clinical	chief complaint
What should be done if there is not enough room near the error to make a correction? A. use white out over the error and write the correction on top of it B. make the correction on a post-it note and place it on top of the error C. write the correction as a line item at the back of the chart D. make a notation near the error as to where the correction may be found	make a notation near the error as to where the correction may be found
How many Cs are there to charting? A. 4 B. 5 C. 10 D. 6	6
Which of the following help keep handwritten entries neat and easy to find? □ writing in pencil so that corrections are easy to make □ using blue or black ink □ making sure handwriting is legible □ using a good-quality pen	using blue or black ink; making sure handwriting is legible; using a good-quality pen
To ensure a professional attitude and tone, which of the following pieces of information should be recorded in medical records? □ opinions or speculations about a patient's problems □ laboratory or test results □ patient's chief complaint in the patient's own words □ physician's observations □ your personal, subjective comments	laboratory or test results; patient's chief complaint in the patient's own words; physician's observations
Individuals who are under the age of 18 and living on their own or are married, parents, or in the armed services are considered A. minors B. adults C. emancipated minors D. late adolescents	emancipated minors
Which of the following means to examine and review a group of patient records for completeness and accuracy? A. audit B. compliance C. evaluation D. review	audit
Which of the following is a guideline that should be followed when releasing medical information? A. obtain verbal consent from the patient to release the information B. file a signed and dated authorization in the patient's medical record C. send information originating from sources outside your facility D. always sent the original material	file a signed and dated authorization in the patient's medical record
Which materials may be used in creating a new patient paper medical record? □ fax machine □ file folders □ hole punch □ labels □ forms □ telephone	file folders; hole punch; labels; forms
Measurable data, such as test results, that are documented in the chart are called: A. assessment data. B. None of these are correct. C. objective data. D. subjective data. E. plan data.	objective data.
A patient's medical history includes: A. All of these are correct. B. occupational history. C. current medications. D. social history. E. family history.	All of these are correct.
Which of the following would not be included on a patient registration form? A. Date of birth B. Allergies C. Insurance D. Current address E. Occupation	Allergies
A patient's symptom is what type of data? A. None of these are correct B. Subjective data C. Plan data D. Objective data E. Assessment data	Subjective data
What is the approved medical abbreviation for family history? A. fl B. ft C. fx D. FH E. fr	FH
When documenting information in a patient chart by problem, this is called: A. OSHA. B. HIPAA. C. POMR. D. CLIA. E. SOAP.	POMR
A valid release of information: A. None of these are correct. B. can be written or verbal. C. can be verbal. D. is not necessary. E. is written.	is written.
Which of the following items does not require documentation in the patient chart? A. All of these must be documented B. Telephone calls C. Consultation reports D. Prescription refills E. Patient follow-up report	All of these must be documented
To help prove that a physician gave appropriate and proper care to a patient: A. all contacts with the patient should be documented in the chart. B. errors should be corrected appropriately. C. abnormal labs should not be filed in the patient's chart D. document all patient contact and correct all errors.	document all patient contact and correct all errors.
Which of the following record types may be corrected or updated? A. Patient medical history B. Provider written notes C. Lab reports D. All of these E. Medical assistant’s written notes	All of these
Which of the following should not be kept in a patient's medical record? A. Diagnosis and treatment plans B. Results of laboratory tests C. Financial information regarding payments D. Medical history E. Correspondence about the patient	Financial information regarding payments
If a patient brings in test results from another physician, the MA should: A. throw them out because you will do your own tests. B. keep them with the chart and document the information. C. keep them with the chart. D. document the information in the chart.	keep them with the chart and document the information.
Medical records that are compiled according to the originator of the data are called: A. alphabetical medical records. B. OSHA. C. SOAP. D. problem-oriented medical records. E. source-oriented medical records.	source-oriented medical records.
A patient's history of present illness includes: A. current medications. B. onset of disease. C. severity of disease. D. severity and onset of disease.	severity and onset of disease.
Informed consent forms are used: A. None of these are correct. B. for physical examination results. C. to allow a medical assistant to take a patient history. D. to record receipt of records from previous physicians. E. to verify that a patient understands treatment options.	to verify that a patient understands treatment options.
Forms that advise the patient on treatment options, risks of procedures, and voluntary participation are called: A. informed consent forms. B. demographic forms. C. authorization forms. D. medication knowledge forms.	informed consent forms.
Which of the following would not be included on a medical history form? A. History of heart murmurs B. Insurance information C. Problems with asthma D. Allergies	Insurance information
Which of the following is not a C of charting? A. Compliant B. Client's words C. Chronological order D. Conciseness E. Clarity	Compliant
If a child lives with his mother who is divorced from his father, the ____ may sign the release of information. A. mother B. father C. child D. None of these are correct E. mother and father	mother and father
The actual medical record belongs to the: A. patient. B. lawyer. C. board of directors. D. insurance company. E. practice.	practice.
Which of the following cannot be released by a medical office? A. Reports from other physicians B. Any information in a patient's chart can be released. C. Surgical reports D. Lab reports E. Dictated notes older than five years	Reports from other physicians
The information in the chart serves to assist in: A. noncompliance B. continuity of care. C. patient education. D. patient registration. E. quality of treatment.	continuity of care.
Which of the following should not be included when documenting in a patient’s medical record? A. Date and time of service B. Lab results C. Physician’s plan of care D. The patient’s own words E. Personal opinions or thoughts	Personal opinions or thoughts
To correct any entry in a medical record, which of the following is true? A. Fully obliterate the original entry. B. Draw a single line through the error, initial and date, then make the correction. C. Enter the corrected information directly over the original entry. D. The provider must sign off on all corrections. E. White-out may be used.	Draw a single line through the error, initial and date, then make the correction.
Which of the following issues is not as much of an issue with dictated/transcribed records? A. Accuracy B. Completeness C. All of these D. Neatness/legibility E. Timeliness	Neatness/legibility

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