Chapter 01: The Medical Record
Bonewit-West: Clinical Procedures for Medical Assistants, 10th Edition

MULTIPLE CHOICE

1. Which of the following is not a function of the medical record?

1. To provide information for making decisions regarding the patient’s care
2. To document the patient’s progress
3. To serve as a legal document
4. To share information between members of the patient’s family

ANS: D REF: p. 2| CAAHEP Competency (2015): VI.4 OBJ: 1

2. What information is contained in the medical record?

1. Health history report
2. Results of the physical examination
3. Laboratory reports
4. Progress notes
5. All of the above

ANS: E REF: pp. 2-3| CAAHEP Competency (2015): VI.4 OBJ: 2

3. The purpose of the HIPAA Privacy Rule is to

1. reduce exposure of patients to bloodborne pathogens.
2. provide patients with betterNcUonRtSroIl NovGeTr tBh.e CusOeMand disclosure of their healthinformation.
3. prevent the patient’s records from being copied.
4. encourage the patient to become more involved in preventive health care.

ANS: B REF: p. 4 | CAAHEP Competency (2015): IX.3 OBJ: 2

4. All of the following are characteristics of the Notice of Privacy Practices except:
a. Was developed by the American Medical Association
b. Must explain how a patient’s health information will be used and protected by the

medical office
c. Must be provided to each patient
d. Must obtain a signed acknowledgment from the patient that he/she has received an

NPP

ANS: A REF: p. 4| CAAHEP Competency (2015): IX.3 OBJ: 2

5. Health information in any form that contains patient identifiable information is known as a. PHI.

b. NPP.
c. OSHA. d. HIPAA.

TEST BANK FOR CLINICAL PROCEDURES FOR MEDICAL ASSISTANTS 10TH EDITION BY BONEWIT-WEST

ANS: A REF: p. 4| CAAHEP Competency (2015): IX.3 OBJ: 2

6. In which of the following situations does HIPAA not require written consent for the use or disclosure of protected health information?

1. Patient referral to a specialist
2. Emergency care provided at a hospital
3. Determination of eligibility for insurance benefits
4. Training of health care students
5. All of the above

ANS: E REF: p. 4| CAAHEP Competency (2015): IX.3 OBJ: 2

7. Which of the following is not an example of a medical office clinical document?

1. Patient registration record
2. Physical examination report
3. Medication record
4. Health history report

ANS: A REF: pp. 2-3| CAAHEP Competency (2015): VI.4 OBJ: 2

8. Which of the following is not a characteristic of a laboratory report?

1. It relays results of laboratory tests to the provider
2. It consists of a report of the analysis or examination of body specimens
3. It assists in diagnosing and treating disease
4. It is a request for laboratory tests to be performed by an outside laboratory

NURSINGTB.COM

ANS: D REF: pp. 2-3| CAAHEP Competency (2015): VI.4 OBJ: 2

9. Which of the following is an example of a diagnostic procedure report?

1. Electrocardiogram report
2. Physical therapy report
3. Urinalysis report
4. Pathology report

ANS: A REF: pp. 2-3| CAAHEP Competency (2015): VI.4 OBJ: 2

10. What is the name of the type of report that documents the assessments and treatments designed to restore a patient’s ability to function?

1. Consultation report
2. Diagnostic procedure report
3. Pathology report
4. Therapeutic service report

ANS: D REF: pp. 2-3| CAAHEP Competency (2015): VI.4 OBJ: 2