1
Which of the following best describes the patient’s idea of treatment success?
Curing the disease
Understanding what caused the illness
Being able to successfully manage the disease
Understanding the physiology of the disease
Getting medications
Being able to successfully manage the disease
Which of the following is usually contained in the first part of the medical history?
Personality
Chief complaint
Mental status
Social history
Cause of illness
Chief complaint
Which of the following is NOT a common medical records format?
Source-oriented
Problem-oriented
Patient-oriented
None of the above
Patient-oriented
Which of the following components of the review of systems would include change in speech?
Neurological
Cardiovascular
Musculoskeletal
Gastrointestinal
Respiratory
Neurological
Which of the following components of the review of systems would include shortness of breath?
Nervous
Cardiovascular
Musculoskeletal
Gastrointestinal
Correct Answer
Respiratory
Respiratory
Which of the following is the most appropriate action when the patient comes into the office for a singular problem and wants to discuss many problems with the physician?
List all the problems under chief complaint.
Remind the patient that the physician’s time is limited, but he will try and accommodate if possible.
Tell the patient not to worry because the physician will meet all his needs.
Tell the patient more time is needed and reschedule the appointment.
Remind the patient that the physician’s time is limited, but he will try and accommodate if possible.
Which of the following best describes the format of a source-oriented medical record?
Notes written in SOAP format
Chronological set of notes for each visit
Database, problem list, and examination
All the objective materials gathered about the patient
Chronological set of notes for each visit
Which of the following is the most appropriate action when the medical assistant is taking the medical history?
Ask the patient whether there are any questions.
Use medical jargon when possible.
Be firm and inflexible.
Ask intimate questions right away to get them over with.
Ask the patient whether there are any questions.
Which of the following best describes the physician’s overall assessment of major body functions?
Review of systems
Disease examination
Past medical history
Family history
Social history
Review of systems
Which of the following is the most appropriate action in order to make a correction when an error has been made in the chart?
Cover with Wite-Out®, write over it, and initial and date it.
Erase the error and correct it.
Scribble out the error and write above it.
Draw a single line through the error. Write the correct entry and put initials and date.
Draw a single line through the error. Write the correct entry and put initials and date.
Which of the following statements is true about interviewing?
Do not worry about comfort level.
Allow the patient to tell anecdotes.
Do not waste time explaining terms or concepts.
Guide the conversation and keep it on track.
Guide the conversation and keep it on track.
Which of the following components of the review of systems includes joint stiffness, muscle pain, and limitation of movement?
Nervous
Cardiovascular
Correct Answer
Musculoskeletal
Gastrointestinal
Respiratory
Musculoskeletal
Which of the following best describe the major components of the problem-oriented medical record?
Problem list, diagnostic and treatment plan, progress notes
Database, problem list, diagnostic and treatment plan
Correct Answer
Database, problem list, diagnostic and treatment plan, progress notes
Database, problem list, diagnostic and treatment plan, laboratory reports
Problem list, diagnostic and treatment plan, progress notes, laboratory reports
Database, problem list, diagnostic and treatment plan, progress notes
Which of the following is NOT a purpose for the patient’s medical history?
Helps guide the patient’s treatment
Allows the provider to recall previous treatment
Allows the patient to help with the diagnosis
Gives a base for statistical analysis
Allows the patient to help with the diagnosis
What is the correct order for information placed chronologically in the chart?
Primary providers notes, EKGs and x-rays, laboratory reports, pathology reports
Primary providers notes, EKGs and x-rays, hospital notes, consultations, correspondence
Primary providers notes, laboratory reports, pathology reports, hospital notes
Primary providers notes, laboratory reports, pathology reports, consultations
Primary providers notes, hospital notes, laboratory reports, medications
Primary providers notes, EKGs and x-rays, hospital notes, consultations, correspondence
Which of the following best describes the first responsibility of the medical assistant when taking the medical history?
Wash hands.
Allow freedom of conversation.
Put the patient at ease.
Follow the exact order of the history form.
Obtain personal information first.
Put the patient at ease.
Which of the following is the most appropriate action of the medical assistant when asking a patient about sensitive topics such as alcohol or drug use?
Ask sensitive questions at the beginning to get uncomfortable moments over.
Do not make eye contact.
Be judgmental when necessary.
Wait until a good rapport with the patient is established before asking sensitive questions.
Wait until a good rapport with the patient is established before asking sensitive questions.
Which of the following is the most appropriate action for the medical assistant with the uncommunicative patient?
Tell the patient that cooperation is mandatory.
Give the patient a sample problem list to review.
Let the physician interview the patient.
Inform the patient of guidelines for expected behavior.
Give the patient a sample problem list to review.
When you ask the patient questions in the history interview, what is the MOST important consideration?
That the patient answer each question
That the patient understand each question
That the patient be allowed to decline to answer
That all questions be repeated
That the patient understand each question
You have picked up your equipment and the supplies necessary to obtain a medical history from a new patient. You introduce yourself to the patient after confirming her identity. Then you attempt to put her at ease. What is the next thing you should do?
Wash your hands.
Begin to ask questions.
Explain the purpose and importance of information gathering.
Ask about allergies.
Explain the purpose and importance of information gathering.
Which of the following is NOT part of the provider’s notice of its privacy act according to the HIPAA privacy rule?
Describes patient’s rights
Explains facilities practices related to PHI
Explains where to file a complaint
Describes various treatment
Describes various treatment
Match the content for each area of the SOAP chart notes with the appropriate description.
subjective; plan; assessment ;objective
symptoms and patient’s complaint
vital signs
weigh subjective and objective findings
further tests and treatment
subjective- symptoms and patient’s complaint
objective- vital signs
assessment -weigh subjective and objective findings
plan -further tests and treatment
Which is NOT a vulnerable area that HIPAA regulations focus on in regard to medical records and the patient’s chart?
Paper record storage
Fax machines
Photocopies
Workstations
Photocopies
Match the charting symbols/abbreviations with the correct meaning.
Δ; WNL; po; XR
by mouth
within normal limits
x-ray
change
by mouth po
within normal limits WNL
x-ray XR
change Δ
Which of the following is NOT a method used for charting?
CHEDDAR
SWISS
SOAP
SOAPER
SWISS