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 Which of the following need not be done when charting? 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? All of the above are correct.
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
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.
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.
Which of the following services may be provided through home health care?
IV therapy
Respiratory care
Rehabilitation
Maternal-child care
All of the above
A consent to treatment form is required for
Tuberculin skin testing
Sebaceous cyst removal
Ear irrigation
Blood pressure measurement
Which of the following is not included in the patient registration record?
Date of birth
Allergies
Employer
Patient’s
insurance company
Flushed skin usually indicates
The patient is experiencing pain
An elevated temperature
The patient has chills
The patient has a rash
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
Which of the following is not included in the social history?
Dietary history
Health habits
Occupation
Chronic illnesses
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
Which of the following is not an example of a diagnostic report?
Urinalysis report
Spirometry report
Colonoscopy report
Radiology report
What information is contained in the medical record?
Health history
Results of the physical examination
Laboratory reports
Progress notes
All of the above
Which of the following reports consists of a macroscopic and microscopic description of tissue removed during surgery?
Laboratory report
Pathology report
Diagnostic imaging report
Operative report
The social history is important, because _____ may affect the patient’s condition.
Lifestyle
Familial diseases
Past injuries
Medications being taken by the patient
A report of the analysis of body specimens is known as a _____ report.
Therapeutic
Diagnostic
Laboratory
Progress
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 is not included in the medical history?
Accidents and injuries
Immunizations
Operations
Medications
Occupation
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”
What term is used to describe the process of making written entries about a patient in the medical record?
Charting
Registration
Scribbling
Documentation
Which of the following provides subjective data about a patient to assist the physician in arriving at a diagnosis?
Laboratory tests
Physical examination
Health history
Diagnostic tests
Which of the following reports consists of an account of the significant events of a patient’s hospitalization?
Emergency department report
Pathology report
History and physical report
Discharge
summary report
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
Data obtained from the patient are recorded in POR progress notes under:
Subjective data
Objective data
Assessment
Plan
Which of the following is an example of a subjective symptom?
Rash
Pain
Dyspnea
Bleeding
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.
Which of the following is included on a medication record for medication administered at the office?
Name of the medication
Route of administration
Dosage administered
Number of refills
All of the above
A yellow color of the skin that is first observed in the whites of the eyes is called
Cyanosis
Hepatitis
Pallor
Jaundice
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
Which of the following can be performed by an electronic medical record software program?
Creation of a medical record
Storage of a medical record
Editing of a medical record
Retrieval of a medical record
All of the above
What term is used to describe dizziness?
Epistaxis
Vertigo
Urticaria
Pruritus
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.
What term is used to describe a patient who
has been admitted to the hospital for at least one overnight stay?
Outpatient
Ambulatory patient
Guest
Inpatient
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 the ICD-10, which term indicates that a condition is not coded here, and the patient cannot have this condition in addition to
the condition listed above it?
Includes
Code first
Excludes 1
Excludes 2
During a routine examination, the physician decides to have an electrocardiogram (ECG) performed on the patient. How should this be coded?
As a separate visit
As a separate procedure
In the code for the office visit
Only if the physician interprets the ECG
What
is the format of most CPT codes?
Two-digit code
Five-digit code
Four-digit code
Three-digit code
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 is the meaning of the “10” in the abbreviation ICD-10-CM?
10th edition
Began to be used in 2010
Up to 10 characters in a code
10 times more codes than ICD-9-CM
Which of the following types of history focuses
mainly on the chief complaint?
Detailed history
Comprehensive history
Problem-focused history
Expanded problem-focused history
Who processes Medicare claims?
The federal government
State insurance companies
The Department of Health and Human Services
Insurance companies that contract with the federal government
What type of number
is usually used to identify the physician who provided each service on an insurance claim form?
NPI number
UPIN number
Social Security number
State medical license number
For which of the following must the patient pay a regular monthly premium?
Medicare Part A
Medicare Part B
Neither A nor B—the cost is the same.
Neither A nor B—there is no cost for either plan.
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)
What type of insurance covers long-term nursing home costs for eligible patients?
Medicaid
Medicare
CHIP plans
None of the above
If a patient with Medicare is admitted to a hospital for three days, what portion of the hospital costs must the patient pay?
Nothing
A deductible of $135.00
The cost of the first day of hospitalization
20% of the amount
charged by the hospital
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
A doctor who participates in Medicare performs a service for which he or she ordinarily charges $350. How much should the physician charge Medicare?
$350
$280
$250
$0
In what type of HMO model are the physicians employed by a managed care organization that provides services in its own offices?
Staff model HMO
Network model HMO
Group practice model HMO
Independent practice association
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
What insurance plan provides for care for patients who are suffering from end-stage
kidney disease?
Medicare
Medicaid
TRICARE
CHAMPUS
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)
Which federal insurance plan provides for services for the elderly and disabled?
Medicare
Medicaid
TRICARE
CHAMPVA
Tom Bloom is a disabled serviceman whose disability is caused by service-related injuries. What insurance plan covers his wife and children?
Medicare
Medicaid
TRICARE
CHAMPVA
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.
What interval(s) is/are commonly used in a manual appointment book or computer
schedule?
5 minutes
10 minutes
30 minutes
45 minutes
All of the above
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 is it important to document missed appointments in the patient’s medical record?
It shows that the patient had an appointment and didn’t keep it.
It is a potential defense against a claim that the physician was not available.
It provides grounds to
terminate a relationship with the patient.
If provides written documentation that the patient does not follow medical advice.
All of the above are correct.
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
Who is responsible for giving the patient written instructions before surgery?
The
surgeon’s office
The primary care physician’s office
The hospital or day surgery center
Written instructions are not necessary
When scheduling surgery for a patient, what information should be provided in addition to the type of surgery, name of the surgery, and name of the surgeon and any assistant surgeon?
The insurance prior authorization number
The exact date that the surgeon wants to perform the
surgery
The name and telephone number of the patient’s next of kin
Whether the patient has completed a living will or health care proxy
All of the above
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
When the patient is going to be admitted to the hospital from home, what should the
medical assistant do?
Make sure there is preauthorization for the admission.
Arrange transportation for the patient.
Schedule the physician to be at the hospital when the patient is admitted.
Instruct the patient not to eat or drink after midnight the night before the admission.
All of the above are correct.
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.