MA CH11
In the CHEDDAR format of documentation, the C section includes
a- contributing information b- consults c- a list of current medications *d- presenting problems e- assessment of the diagnostic process
The P section of SOAP documentation is ____.
a- data provided by test results b- data provided by the physician *c- the plan of action d- the diagnosis or impression of the patients problem e- data provided by the patient
In legal terms, medical records regarded as ____ may damage a physician's position in a lawsuit.
a- due course b- prompt c- development d- responsible *e- convenient
In addition to being essential documents for patient care management, patient records are used for ____.
a- evaluating patient satisfaction b- advertising physician services c- evaluating public records *d- providing patient education e- showing results to other patients
When should you record exam and test results?
a- every monday morning b- every friday afternoon c- every other friday d- once a month *e- as soon as they are availible
Objective or external factors that can be seen or felt by the practitioner or measured by an instrument are called ____.
a- feelings b- behavior c- outcomes *d- signs e- symptoms
The most appropriate way to terminate an initial interview with the patient is ____.
a- "are you sure you haven't forgotten to tell me anything?" *b- "is there anything else you would like the doctor to know?" c- "the lab technician will be in to draw blood" d- "i need to terminate this interview" e- "the doctor will be in shortly"
What does the A in SOAP documentation stand for?
a- alternative b- action c- adjusted d- application *e- assessment
Which of the following organizations reviews patient health records to monitor whether the care provided and the fee charged met accepted standards?
a- american hospital association *b- the joint commission c- american medical association d- american medical society e- professional board of medical examiners
The best way to make sure the licensed practitioner sees a patient's X-ray report before filing it is to _____.
a- ask the patient to give the report to the practitioner b- place the results on the practitioners desk c- tell the nurse to tell the practitioner the results d- give the report to another practitioner in the office to give to the practitioner *e- have the practitioner initial the report
The best place to interview a patient is ____.
a- at any convenient location b- at the reception desk c- in the hallway leading to the exams room d- in the patient waiting room *e- in a private room
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 ____.
a- attempt to call and relay the physicians message later b- attempt to call and leave a message for the patient c- leave the physician a note to call again d- remind the physician to call again later *e- record and date the call in the patient record
The type of documentation that provides an orderly series of steps for dealing with any medical case is ____.
a- charting by exception b- focus charting c- daily charting *d- SOAP e- source recording
In which section of the CHEDDAR format of documentation can the diagnosis be found?
a- chief complaint *b- assessment c- examination d- details of problems and complaints e- history
Kenneth is preparing copies of X-ray and lab results from Mrs. Vendel's chart to be mailed to another physician's office. He tells you that he thinks this is a waste of time, but Mrs. Vendel called and requested that the records be sent to the other physician's office for a second opinion. How should you respond?
*a- "has mrs. vendel signed a written consent to have the record transferred" b- "mrs vendel is infamous for wanting second opinions; we do this all the time" c- "if she likes the second opinion, we may lose mrs vendels business" d- "im not busy right now; do you want any help copying the records" e- "its a good thing she called in person so that she could authorize the transfer
Internal audits are done
*a- by medical staff on random record b- by agencies from outside the medical practice c- by the federal government d- at a patients request e- to catch medical errors
Documenting a patient's walk down a hall as "fine" violates which "C" of charting?
*a- clarity b- confidentiality c- chronological order d- completeness e- conciseness
In the problem-oriented medical record (POMR), which of the following includes a record of the patient's history, information from the initial interview, and any tests?
*a- database b- educational, diagnostic, and treatment plan c- problem list d- progress note e- subjective notes
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 ____.
*a- due course b- transcription c- development d- convenient e- sequencing
One of the most important duties of a medical assistant is to ____.
*a- fill out and maintain accurate and thorough patient records b- review patient charts to monitor the care provided c- explain how the patients general health has improved or lessened d- point out to the patient how test results have changed e- tell the physician what is wrong with the patient
Patient records are used in medical research ____.
*a- for data regarding patient responses and side effects b- for experimentation with treatment that has not yet been approved c- only occasionally, because it is usually considered illegal d- as a means to get research money e- to determine the average amount being paid for health insurance
An example of a patient symptom is ____.
*a- pain b- fever c- swelling d- rash e- high blood pressure
The first document found in a patient's financial record is the ____.
*a- patient registration form b- record from other physicians or hospitals c- doctors diagnosis and treatment plan d- patient medical history e- signed informed consent form
The purpose of having a patient sign an informed consent form is to ensure that the ____.
*a- patient understands the treatment offered and the possible outcomes b- physician does not have to document every visit c- physician can delegate the patients care to the medical assistant d- physician may terminate care at any time e- patient has a legal recourse against the physician
Which of the following is appropriate when correcting a medical record?
*a- place a note near the correction stating why it was made b- type the correct information over the incorrect data c- erase the incorrect information and enter the new information d- write the date and your initials at the end of the medical record e- black out the incorrect information
Subjective or internal conditions felt by the patient are ____.
*a- symptoms b- goals c- signs d- outcomes e- responses
The patient's name is Patty Billingsford. She is single and works as an administrative assistant at Smith Brothers Investment Company. Her phone number is 555-123-4567, and her social security number is: 355-23-6789. She was referred to Dr. Elizabeth Williams by Mary Ann Smith, the wife of her boss at Smith Brothers. She puts her parents Robert and Lydia Billingsford down as her emergency contact. Their number is 555-855-2266. She only has the primary insurance for herself. Using the patient's Driver's License and Insurance card, fill in the information in the Patient Registration form below in the yellow-highlighted boxes. Make sure to input the information precisely as it is given in the scenario, paying close attention to correct spelling.
DON'T WORRY ABOUT THIS QUESTION, IT PERTAINS TO A PICTURE ON THE HOMEWORK
The reason a patient's record should not be sent by fax machine is that ____.
a- it takes to long to fax each page b- fax machines are unreliable c- copies from a fax machine are difficult to read *d- there is no way to tell who will see the document e- the digital transmission from a fax machine can be corrupted
Which of the following information is found on the patient registration form?
a- laboratory results from another physician b- social and occupational history *c- name of the person to contact in an emergency d- use of alcohol or drugs e- patient allergies
"The patient got out of bed and walked 20 feet without reporting or displaying signs of shortness of breath" is an example of ____ in documentation.
a- lack of completeness b- using the clients words *c- clarity d- too much detail e- breach of confidentiality
Information such as laboratory results that are required quickly are commonly sent to the medical facility by which method?
a- mail *b- fax c- delivery person d- phone e- telling the physician what is wrong with the patient
Important information about a patient's medical history and present condition is found in the ____.
a- medical transcription *b- patients health record c- problem-oriented medical record system d- medical office record book e- scheduling or appointment book
An example of a patient sign is ____.
a- nausea *b- a rash c- pain d- a headache e- a tingling sensation
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 ____.
a- patient medical history b- physician examination form c- patient registration form *d- hospital discharge summary e- laboratory results
A patient's illness and the reason for a visit to the medical office are found in the ____.
a- patient test results b- informed consent form c- patient medical history *d- patient registration form e- records from other healthcare providers
Which of the following is necessary to release a patient's record to the patient's insurance company?
a- patients verbal consent b- physicians permission c- verification of the insurance company *d- patients written consent e- either the patients consent or the physicians release
A medical record received from another health provider should be ___.
a- placed in a file in the medical office b- given to the patient to keep *c- entered into the patients chart d- shredded to maintain confidentiality e- kept in the physicians office for reference
What color is used by some facilities to ensure handwritten records are the original versus a copy?
a- red b- black *c- blue d- green
A guideline for releasing medical information is to ____.
a- release all the patients records, including those from other facilities b- fax all confidential materials c- send the original documents d- have the patient give a verbal consent *e- call the recipient to confirm that all materials were received
Audits that are done by medical staff before patient billing is submitted are ____.
a- retrospective external audits b- introspective internal audits c- retrospective internal audits d- prospective external audits *e- prospective internal audits
The appropriate way to delete information on a medical record is to ____.
a- retype the entire record, leaving out the information to be deleted b- erase the mistaken data *c- draw a line through the original information so it is still legible d- scratch out the incorrect information e- use correction fluid to cover it up
The O section of SOAP documentation is ____.
a- the diagnosis or impression of a patients problem *b- data that comes from examination results and from the physician c- data that comes from the patient d- the plan of action, including follow-up e- a description of treatment options
The S section of SOAP documentation is ____.
a- the diagnosis or impression of a patients problem b- a description of treatment options c- data that comes from the physician or test results *d- data that comes directly from the patient e- the plan of action
The right to sign a release-of-records form for a child when the parents are divorced belongs to ____.
a- the father b- the physician c- the court system *d- either the mother or the father e- the mother
The role the medical assistant plays in patient education is to explain ____.
a- the outcome of the disease *b- management of the patients condition as outlined by the practitioner c- what treatment is appropriate d- how the patient should manage pain associated with the condition e- test results
The A section of SOAP documentation includes ____.
a- the plan of action b- data that comes from examination results and from the physician *c- the diagnosis of impression of a patients problem d- a description of treatment options e- data from the patient
Recording information in the medical record is called ____.
a- transcription b- filing *c- documentation d- dictation e- description
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?
a- use correction fluid to cover the old information to make space for new information b- write as small as possible and continue sentences on the back of the sheet c- use as many abbreviations as necessary to make all of the new information fit *d- make a note on the patients registration to "see the updated registration sheet" e- shred the old registration sheet and create and entirely new one
When do most states consider children to be adults with the right to privacy?
a- when the child has a job b- age 25 c- age 21 *d- age 18 e- age 16
When is it appropriate to send the original documents in a patient's health record?
a- when the record is going to another physician *b- when a record is subpoenaed for a court case c- never d- when the patient signs an authorization to release them e- when the insurance company specifically requests them
