What are data obtained from the patient are recorded in Por progress notes under?

When a medical assistant witnesses a patient’s signature, it means that he or she verified:
The patient’s identity and watched the patient sign the form
That the information on the form is correct
That the patient is aware of the risks involved with the procedure to be performed
That the physician discussed informed consent with the patient

The patient’s identity and watched the patient sign the form

Which of the following need not be done when charting?
Begin each new entry on a separate line.
Include the patient’s name at the beginning of each entry.
Begin each phrase with a capital letter.
Include the date and time with each entry.

Include the patient’s name at the beginning of each entry.

Which of the following can be used to enter a health history into an electronic medical record?
The patient completes a paper form, and the medical assistant scans it into the computer.
The medical assistant enters information while asking the patient questions.
The patient completes a health history on a computer.
All of the above are correct.

All of the above are correct.

What is the chief complaint?
The probable outcome of the patient’s condition
The symptom causing the patient the most trouble
A detailed description of the patient’s illness using medical terms
A tentative diagnosis of the patient’s condition

The symptom causing the patient the most trouble

What is an objective symptom?
A symptom that can be observed by another person
A symptom that precedes a disease
A symptom that is felt by the patient and cannot be observed by another
The symptom causing the patient the most trouble

A symptom that can be observed by another person

The purpose of the tab on a file folder is to
Hold documents in place in the folder.
Identify the contents of the folder.
Prevent the folder from being misfiled.
Keep the folder closed when not in use.

Identify the contents of the folder.

A copy of the patient’s emergency department report is sent to the
Patient’s insurance company
Patient
Patient’s family physician
Laboratory

Patient’s family physician

Which of the following does not assist in the collection of data for a health history?
A quiet, comfortable room
Showing interest in the patient
Showing concern for the patient
Calling the patient “honey”

Calling the patient “honey”

Which of the following must be included in informed consent?
An explanation of risks involved with the procedure
Any alternative treatments or procedures available
The prognosis
The purpose of the recommended procedure
All of the above

An explanation of risks involved with the procedure

Why should a recording in the medical record never be erased or obliterated?
It makes it harder to read the chart.
The patient may not receive the proper care.
Credibility is reduced if the physician is involved in litigation.
It indicates the procedure was performed incorrectly.

Credibility is reduced if the physician is involved in litigation.

The health history is taken
After the physician performs the physical examination
After laboratory test results are reviewed
Before the physician performs the physical examination
After the physician makes a diagnosis of the patient’s condition

Before the physician performs the physical examination

Black ink should be used when recording in the patient’s chart to
Provide a permanent record.
Ensure legible handwriting.
Avoid spelling errors.
Reduce charting errors.

Provide a permanent record.

Why is it important to document any instructions provided to the patient?
To ensure that the patient understands the instructions provided
To protect the physician legally if the patient is harmed by not following the instructions
To ensure that the patient follows the instructions
To provide a record for the insurance company

To protect the physician legally if the patient is harmed by not following the instructions

How is an established patient defined?
A patient who has been seen in consultation
A patient who has been seen in the past three years
A patient who has made a payment to the office
A patient who has a medical record in the office

A patient who has been seen in the past three years

In which section of the CPT manual is there an attempt to link reimbursement to the completeness of the examination and the amount of skill required to manage the patient’s problems?
Primary Care
Initial Consultation
Diagnosis Establishment
Evaluation and Management

Evaluation and Management

What classification system forms the basis for payments for claims under Medicare Part A?
Title XIX (Title 19) fees
Diagnostic-related groups (DRGs)
Usual, customary, and reasonable charges (UCR)
A resource-based relative value system (RBRVS)

Usual, customary, and reasonable charges (UCR)

With which of the following things having to do with each insurance plan accepted by the medical office need the medical assistant not be familiar?
The procedure to request a referral to a specialist
The specific procedures covered by each patient’s insurance
The laboratories where patients may have laboratory tests performed
The medical facilities where patients may have procedures or diagnostic tests done

The specific procedures covered by each patient’s insurance

Mary and Tom Weatherly are both covered by a family health insurance plan. Whose plan is the primary plan for their children?
Whoever earns the highest annual income
Whoever’s birthday comes first in the year
Whoever has worked the longest
Whoever’s birthday falls the closest to the child’s

Whoever’s birthday comes first in the year

If a patient has managed care insurance, who is the usual gatekeeper to authorize consultations with specialists?
The referral coordinator
The nurse practitioner
The primary care provider
An employee at the managed care insurance company

The primary care provider

In which of the following types of insurance does the subscriber belong to both an HMO and an insurance plan?
Point of Service plan (POS)
Preferred Provider Organization (PPO)
Exclusive Provider Organization (EPO)
Independent Practice Association (IPA)

Point of Service plan (POS)

Historically, how did health insurance become linked with an individual’s employment?
One of the first insurance plans was arranged by a group of Dallas schoolteachers.
As an employee benefit, health insurance can increase functional income without affecting taxable income.
The insurance industry wanted to expand from accident insurance to more comprehensive health insurance.
The industrial revolution increased the likelihood of on-the-job injury, resulting in higher health costs for workers.

One of the first insurance plans was arranged by a group of Dallas schoolteachers.

When is double-booking often used?
When the physician uses two examination rooms
When a patient with an acute injury or illness must be fitted into the schedule
When there is more than one physician scheduled to be in the office
When the physician is running behind schedule

When a patient with an acute injury or illness must be fitted into the schedule

Why must proper procedures be adhered to in scheduling patients for consultations with specialists?
Specialists will only accept patients who are referred by another physician.
Managed care insurance often requires written referral forms, or it will not pay.
The physician must demonstrate that the patient needs the service.
The specialist needs to have a complete history on the patient before seeing him.

Managed care insurance often requires written referral forms, or it will not pay.

What information must be obtained from a new patient?
The patient’s work schedule
The patient’s past medical history
Whether the patient smokes cigarettes
The type of medical insurance and coverage

The type of medical insurance and coverage

Which of the following variables will affect the appointment matrix the most?
The availability of facilities and equipment
The season of the year
The type of scheduling system used by the office
The location of examination rooms within the office

The availability of facilities and equipment

What is the goal of stream scheduling?
To schedule the same amount of time for each appointment
To be sure that there is always a patient waiting to see the physician
To give the physician time to respond to telephone messages between patients
To schedule patients so that there is a steady flow of patients moving through the office

To schedule patients so that there is a steady flow of patients moving through the office

What is important when changing the appointment date and time for a patient?
Delete or erase the original appointment completely.
Record that the appointment was changed in the patient’s medical record.
Always draw a line through the original appointment if a manual appointment book is used.
Give the patient an appointment within 2 days of the original appointment, double-booking if necessary.

Delete or erase the original appointment completely.