HW#11_NCMA (NCCT) Exam Prep #3 Flashcards
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.
Which of the following services may be provided through home health care? IV therapy Respiratory care Rehabilitation Maternal-child care All of the above
All of the above
A consent to treatment form is required for Tuberculin skin testing Sebaceous cyst removal Ear irrigation Blood pressure measurement
Tuberculin skin testing
Which of the following is not included in the patient registration record? Date of birth Allergies Employer Patient’s insurance company
Allergies
Flushed skin usually indicates The patient is experiencing pain An elevated temperature The patient has chills The patient has a rash
An elevated temperatur
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
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
Urinalysis report
What information is contained in the medical record? Health history Results of the physical examination Laboratory reports Progress notes All of the above
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
Pathology report
The social history is important, because \_\_\_\_\_ may affect the patient’s condition. Lifestyle Familial diseases Past injuries Medications being taken by the patient
Lifestyle
A report of the analysis of body specimens is known as a \_\_\_\_\_ report. Therapeutic Diagnostic Laboratory Progress
Laboratory
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
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
Charting
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
Health history
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
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
Subjective data
Which of the following is an example of a subjective symptom? Rash Pain Dyspnea Bleeding
Pain
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
Name of the medication