BAYES MEDICAL OFFICE PROCEDURES 8TH ED – TEST BANK

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Sample Questions Posted Below

 

 

 

 

Chapter 05

Managing Health Information

 

 

Multiple Choice Questions

  1. Another name for a central computer is:
    A.Network
    B. File server
    C. Hard drive
    D. Program

Another name for a central computer is a file server.

 

ABHES: 7.a
Blooms: Remember
CAAHEP: V.P.6
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.01
Topic: Computer Usage

 

  1. Online medical _____ are used to educate physicians concerning conditions and treatment regimes.
    A.Games
    B. Companions
    C. Databases
    D. Courses

Online medical databases are used to educate physician’s concerning conditions and treatment regimes.

 

ABHES: 7.a
ABHES: 7.b
Blooms: Remember
CAAHEP: V.P.6
CAHIIM: II.A.1
CAHIIM: II.A.2
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.01
Topic: Computer Usage

  1. Most medical billing offices use an electronic medical billing program. Which of these is one example of such a program?
    A.Medicare
    B. Medisoft
    C. Medidata
    D. Medical Manager

Most medical billing offices use a medical billing program such as Medisoft.

 

ABHES: 7.b
ABHES: 8.b
ABHES: 8.c
Blooms: Remember
CAAHEP: VI.P.2.b
CAHIIM: I.D.1
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.01
Topic: Computer Usage

 

  1. Accurate financial records are required for _____ and are critical for the practice’s success.
    A.Billing
    B. Purchasing
    C. Tax reporting
    D. Employee payroll

Accurate financial records are required for tax reporting and are critical for the practice’s success.

 

ABHES: 8.b
ABHES: 8.c
Blooms: Remember
CAAHEP: VI.C.2
CAHIIM: I.A.1
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.01
Topic: Computer Usage

  1. One of the most important tasks of an administrative medical assistant is the creation of:
    A.Patient data
    B. Patient accounts
    C. Practice documents
    D. Health insurance claims

One of the most important tasks of an administrative medical assistant is the creation of health insurance claims.

 

ABHES: 8.b
ABHES: 8.c
Blooms: Remember
CAAHEP: VII.P.3
CAHIIM: I.C.1
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.01
Topic: Computer Usage

 

  1. The abbreviation EFT stands for:
    A.Electronic funds trade
    B. Electronic forms trade
    C. Electronic forms transfer
    D. Electronic funds transfer

The abbreviation EFT stands for electronic funds transfer.

 

ABHES: 3.d
Blooms: Remember
CAAHEP: IV.C.11
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.01
Topic: Computer Usage

  1. _____ computers are the most powerful computers available.
    A.Mini
    B. Super
    C. Mainframe
    D. Personal

Supercomputers are the most powerful computers available.

 

ABHES: 7.a
Blooms: Remember
CAAHEP: V.P.6
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.01
Topic: Computer Usage

 

  1. _____ computers are used in large businesses, hospitals, large clinics, and government organizations.
    A.Mainframe
    B. Mini
    C. Super
    D. Personal

Mainframe computers are used in large businesses, hospitals, large clinics, and government organizations.

 

ABHES: 7.a
Blooms: Remember
CAAHEP: V.P.6
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.01
Topic: Computer Usage

  1. _____ computers have less power than mainframes.
    A.Hospital
    B. Super
    C. Giant
    D. Mini

Mini computers have less power than mainframes.

 

ABHES: 7.a
Blooms: Remember
CAAHEP: V.P.6
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.01
Topic: Computer Usage

 

  1. To avoid unnecessary neck and eyestrain when using a computer, position the monitor at or below eye level, between ________ away.
    A.1 and 1.5 feet
    B. 2 and 2.5 feet
    C. 3 and 3.5 feet
    D. 4 and 5.5 feet

To avoid unnecessary neck and eyestrain when using a computer, position the monitor at or below eye level, between 2 and 2.5 feet away.

 

ABHES: 7.a
Blooms: Remember
CAAHEP: V.P.6
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.01
Topic: Computer Usage

  1. A(n) _____ is a standard version of a document that is used over and over again.
    A.Template
    B. Form
    C. Stencil
    D. Sample

A template is a standard version of a document that is used over and over again.

 

ABHES: 7.a
ABHES: 7.b
ABHES: 8.a
Blooms: Remember
CAAHEP: V.C.5
CAAHEP: V.P.5
CAHIIM: I.A.2
CAHIIM: I.B.1
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.01
Topic: Computer Usage

 

  1. What can be assigned to limit the number of individuals who have access to particular computer files and to help users create a computerized audit trail?
    A.Locks
    B. Log-ons
    C. Permissions
    D. Passwords

Passwords are assigned to limit the number of individuals who have access to particular computer files and to help users create a computerized audit trail.

 

ABHES: 7.b
Blooms: Remember
CAAHEP: IX.P.1
CAHIIM: I.A.2
CAHIIM: I.B.1
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.01
Topic: Computer Usage

  1. A patient’s medical record constitutes the _____ record of the medical practice.
    A.Established
    B. Official
    C. Legal
    D. Valid

A patient’s medical record constitutes the legal record of the medical practice.

 

ABHES: 4.f
Blooms: Remember
CAAHEP: IX.P.7
CAHIIM: I.A.2
CAHIIM: I.B.1
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.02
Topic: The Medical Record

 

  1. Making corrections to a chart with an eraser or scribbling out entries could present the appearance of _______________.
    A.A mistake
    B. Carelessness
    C. Fraud
    D. Cheating

Making corrections to a chart with an eraser or scribbling out entries could present the appearance of fraud.

 

ABHES: 4.a
ABHES: 4.f
Blooms: Remember
CAAHEP: IX.P.7
CAHIIM: I.A.2
CAHIIM: I.B.1
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.02
Topic: The Medical Record

  1. If you make an error while recording an entry in the medical record, do all of the following except
    A. Write the word “error” next to the error.
    B. Write your initials next to error.
    C. Use correction tape to keep the entry neat.
    D. Write the date next to the error.

If you make an error while recording an entry in the medical record, do not use correction tape in an attempt to keep the entry neat.

 

ABHES: 4.a
ABHES: 4.f
Blooms: Remember
CAAHEP: IX.P.7
CAHIIM: I.A.2
CAHIIM: I.B.1
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.02
Topic: The Medical Record

 

  1. Offices using electronic medical record entry methods should affix what to all chart entries?
    A.A label
    B. A validation code
    C. An electronic date stamp
    D. An electronic signature

Offices using electronic medical record entry methods should affix an electronic signature to all chart entries.

 

ABHES: 7.b
Blooms: Remember
CAAHEP: V.P.6
CAHIIM: I.B.2
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.02
Topic: The Medical Record

  1. A chronological record of ongoing patient care and progress is also known as
    A.A chart note.
    B. A chart plan.
    C. A legal note.
    D. A patient plan.

A chart note is a chronological record of ongoing patient care and progress.

 

ABHES: 4.a
Blooms: Remember
CAAHEP: V.C.5
CAAHEP: V.C.6
CAAHEP: V.P.3
CAHIIM: I.A.2
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.02
Topic: The Medical Record

 

  1. What method is the most common system for outlining and structuring chart notes for a medical record?
    A.CHEDDAR
    B. SOAP
    C. POMR
    D. SOMR

The SOAP method is the most common system for outlining and structuring chart notes for a medical record.

 

ABHES: 4.a
Blooms: Remember
CAAHEP: V.C.5
CAAHEP: V.C.6
CAAHEP: V.P.3
CAHIIM: I.A.2
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.06
Topic: Documentation Formats

  1. Which charting format breaks down the components of a patient encounter into seven detail-oriented sections?
    A.CHEDDAR
    B. SOAP
    C. POMR
    D. SOMR

The CHEDDAR charting format breaks down the components of a patient encounter into seven detail-oriented sections.

 

ABHES: 4.a
Blooms: Remember
CAAHEP: V.C.5
CAAHEP: V.C.6
CAAHEP: V.P.3
CAHIIM: I.A.2
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.06
Topic: Documentation Formats

 

  1. The _____ findings in a SOAP record are the physician’s examination of the patient.
    A.Subjective
    B. Objective
    C. Assessment
    D. Plan

The objective findings in a SOAP record are the physician’s examination of the patient.

 

ABHES: 4.a
Blooms: Remember
CAAHEP: V.C.5
CAAHEP: V.C.6
CAAHEP: V.P.3
CAHIIM: I.A.2
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.06
Topic: Documentation Formats

  1. The _____ findings in a SOAP record are the patient’s description of the problem or the complaint.
    A.Subjective
    B. Objective
    C. Assessment
    D. Plan

The subjective findings are the patient’s description of the problem or the complaint.

 

ABHES: 4.a
Blooms: Remember
CAAHEP: V.C.5
CAAHEP: V.C.6
CAAHEP: V.P.3
CAHIIM: I.A.2
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.06
Topic: Documentation Formats

 

  1. Based on the Master Problem List and the initial problems of the patient, the physician
    A.Makes a diagnosis.
    B. Makes a prognosis.
    C. Begins a course of treatment.
    D. Defines an outcome.

Based on the Master Problem List and the initial problems of the patient, the physician begins a course of treatment and details in narrative or flowchart format.

 

ABHES: 4.a
Blooms: Remember
CAAHEP: V.C.5
CAAHEP: V.C.6
CAAHEP: V.P.3
CAHIIM: I.A.2
CAHIIM: I.B.1
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.06
Topic: Documentation Formats

  1. All medical records should be kept until:
    A.The physician retires
    B. The practice closes
    C. The patient dies
    D. The possibility of a malpractice suit has passed

All medical records should be kept until the possibility of a malpractice suit has passed.

 

ABHES: 4.b
ABHES: 4.f
Blooms: Remember
CAAHEP: V.P.3
CAHIIM: I.B.1
CAHIIM: I.B.2
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.07
Topic: Ownership, Quality Assurance, and Record Retention

 

  1. When a patient has died, moved away, or terminated their relationship with the physician, the file is considered to be:
    A.Active
    B. Closed
    C. Inactive
    D. Retired

When a patient has died, moved away, or terminated their relationship with the physician, the file is considered to be closed.

 

ABHES: 4.b
ABHES: 4.f
Blooms: Remember
CAAHEP: V.P.4
CAHIIM: I.B.1
CAHIIM: I.B.2
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.07
Topic: Ownership, Quality Assurance, and Record Retention

  1. What is the best measurement of the quality of care given to a patient?
    A.The medical record
    B. Patient compliance
    C. The physician’s reputation
    D. Patient cure rate

The best measurement of the quality of care given to a patient is the medical record.

 

ABHES: 4.a
Blooms: Understand
CAAHEP: IX.P.7
CAHIIM: I.B.1
CAHIIM: I.B.2
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.07
Topic: Ownership, Quality Assurance, and Record Retention

 

  1. Patients ____ the right to inspect their medical documentation.
    A.have
    B. do not have
    C. must earn
    D. may sue the physician for

Patients have the right to inspect their medical documentation.

 

ABHES: 4.a
ABHES: 4.b
Blooms: Remember
CAAHEP: IX.C.4
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.07
Topic: Ownership, Quality Assurance, and Record Retention

  1. Which type of file pertains to current patients?
    A.Inactive
    B. Active
    C. Closed
    D. Closed storage

An active file pertains to current patients.

 

ABHES: 4.a
Blooms: Understand
CAAHEP: V.C.5
CAAHEP: V.C.6
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.07
Topic: Ownership, Quality Assurance, and Record Retention

 

  1. Which type of file relates to patients who have not seen the physician for six months?
    A.Active
    B. Inactive
    C. Closed
    D. Closed storage

An inactive file relates to patients who have not seen the physician for six months.

 

ABHES: 4.a
Blooms: Remember
CAAHEP: V.C.5
CAAHEP: V.C.6
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.07
Topic: Ownership, Quality Assurance, and Record Retention

  1. Federal law _____ regulate retention time frames for patient’s medical records.
    A.Does
    B. Does not
    C. May opt to
    D. Can, in some cases

Federal law does not regulate retention time frames for patient’s medical records.

 

ABHES: 4.f
Blooms: Remember
CAAHEP: IX.A.3
CAHIIM: I.B.2
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.07
Topic: Ownership, Quality Assurance, and Record Retention

 

  1. All ____ records must be kept according to the same retention schedule as that for older paper records.
    A.Physician
    B. Photocopied
    C. Inactive or closed
    D. Electronically stored

All electronically stored records must be kept according to the same retention schedule as that for older paper records.

 

ABHES: 4.f
Blooms: Remember
CAAHEP: V.C.5
CAAHEP: V.C.6
CAHIIM: I.B.2
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.07
Topic: Ownership, Quality Assurance, and Record Retention

  1. Records that have been closed and those that must be kept permanently are said to be in _____ storage, a storage area separate from the area where active files are kept.
    A.Secure
    B. Active
    C. Safe
    D. Dead

Records that have been closed and those that must be kept permanently are said to be in dead storage, or storage separate from the area where active files are kept.

 

ABHES: 4.b
ABHES: 4.f
Blooms: Remember
CAAHEP: V.C.5
CAAHEP: V.C.6
CAHIIM: I.B.2
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.07
Topic: Ownership, Quality Assurance, and Record Retention

 

  1. Dead storage ________ be easily accessible.
    A.Needs to
    B. Need not
    C. Can
    D. Will never

Dead storage need not be easily accessible.

 

ABHES: 4.b
ABHES: 4.f
Blooms: Remember
CAAHEP: V.C.5
CAAHEP: V.C.6
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.07
Topic: Ownership, Quality Assurance, and Record Retention

  1. In the medical office, how many main types of records are there?
    A.One
    B. Two
    C. Three
    D. Four

There are three main types of records in the medical office: patient medical records, correspondence related to healthcare, and practice management records.

 

ABHES: 4.a
Blooms: Remember
CAAHEP: V.C.5
CAAHEP: V.C.6
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.08
Topic: Filing Systems

 

  1. The central responsibility of the physician’s practice is:
    A.Patient reviews
    B. Patient care
    C. Preventative visits
    D. Patient payment

The central responsibility of the physician’s practice is patient care.

 

ABHES: 1.b
Blooms: Remember
CAAHEP: IX.C.1
CAAHEP: IX.C.7
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.08
Topic: Filing Systems

  1. Which type of files are kept in one place?
    A.Decentralized
    B. Centralized
    C. Dead
    D. Open-shelf files

Centralized files are kept in one place.

 

ABHES: 4.a
ABHES: 4.b
Blooms: Remember
CAAHEP: V.C.10
CAAHEP: V.C.5
CAAHEP: V.C.6
CAAHEP: V.C.7
CAAHEP: V.C.9
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.08
Topic: Filing Systems

 

  1. Information of use to only one staff member, such as a physician’s correspondence, is stored in a _____ file convenient to the user.
    A.Decentralized
    B. Centralized
    C. Dead
    D. Open-shelf

Information of use to only one staff member, such as a physician’s correspondence, is stored in a decentralized file convenient for the user.

 

ABHES: 4.a
Blooms: Remember
CAAHEP: V.C.10
CAAHEP: V.C.5
CAAHEP: V.C.6
CAAHEP: V.C.7
CAAHEP: V.C.9
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.08
Topic: Filing Systems

  1. The need to conserve space in many offices has made _____ files popular.
    A.Centralized
    B. Dead
    C. Decentralized
    D. Open-shelf

The need to conserve space in many offices has made open-shelf files popular.

 

ABHES: 4.a
Blooms: Remember
CAAHEP: V.C.10
CAAHEP: V.C.5
CAAHEP: V.C.6
CAAHEP: V.C.7
CAAHEP: V.C.9
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.08
Topic: Filing Systems

 

  1. Which type of files save time and labor but may sacrifice some security?
    A.Open-shelf files
    B. Decentralized files
    C. Dead files
    D. Centralized files

Open-shelf files save time and labor, but they are not very secure.

 

ABHES: 4.a
Blooms: Remember
CAAHEP: V.C.10
CAAHEP: V.C.5
CAAHEP: V.C.6
CAAHEP: V.C.7
CAAHEP: V.C.9
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.08
Topic: Filing Systems

  1. Which type of files are arranged from front to back?
    A.Open-shelf files
    B. Centralized files
    C. Vertical files
    D. Centralized files and vertical files

Centralized files and vertical files are arranged from front to back.

 

ABHES: 4.a
Blooms: Understand
CAAHEP: V.C.10
CAAHEP: V.C.5
CAAHEP: V.C.6
CAAHEP: V.C.7
CAAHEP: V.C.9
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.08
Topic: Filing Systems

 

  1. Which type of files are arranged from left to right, instead of from front to back?
    A.Open-shelf files
    B. Centralized files
    C. Vertical files
    D. Lateral files

Lateral files are arranged from left to right, instead of from front to back.

 

ABHES: 4.a
Blooms: Remember
CAAHEP: V.C.10
CAAHEP: V.C.5
CAAHEP: V.C.6
CAAHEP: V.C.7
CAAHEP: V.C.9
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.08
Topic: Filing Systems

  1. File folders may be open on how many sides?
    A.One and two only
    B. Two and three only
    C. One and three only
    D. One, two, or three

File folders may be open on one, two, or three sides.

 

ABHES: 4.a
Blooms: Remember
CAAHEP: V.C.10
CAAHEP: V.C.5
CAAHEP: V.C.6
CAAHEP: V.C.7
CAAHEP: V.C.9
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.08
Topic: Filing Systems

 

  1. How many steps are included in filing?
    A.Five
    B. Four
    C. Three
    D. Two

Five steps are included in filing.

 

ABHES: 4.a
Blooms: Remember
CAAHEP: V.C.10
CAAHEP: V.C.5
CAAHEP: V.C.6
CAAHEP: V.C.7
CAAHEP: V.C.9
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.08
Topic: Filing Systems

  1. _____ is the mental process of selecting the name, title, or classification under which an item will be filed.
    A.Sorting
    B. Storing
    C. Coding
    D. Indexing

Indexing is the mental process of selecting the name, title, or classification under which an item will be filed.

 

ABHES: 4.a
Blooms: Remember
CAAHEP: V.C.10
CAAHEP: V.C.5
CAAHEP: V.C.6
CAAHEP: V.C.7
CAAHEP: V.C.9
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.08
Topic: Filing Systems

 

  1. _____ is the placing of a number, a letter, or an underscore beneath a word to indicate where the document should be filed.
    A.Coding
    B. Indexing
    C. Sorting
    D. Storing

Coding is the placing of a number, a letter, or an underscore beneath a word to indicate where the document should be filed.

 

ABHES: 4.a
Blooms: Remember
CAAHEP: V.C.10
CAAHEP: V.C.5
CAAHEP: V.C.6
CAAHEP: V.C.7
CAAHEP: V.C.9
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.08
Topic: Filing Systems

  1. What type of file should be consulted daily?
    A.Centralized
    B. Tickler
    C. Decentralized
    D. Cross-reference

A tickler file should be consulted daily.

 

ABHES: 4.a
Blooms: Remember
CAAHEP: V.C.10
CAAHEP: V.C.5
CAAHEP: V.C.6
CAAHEP: V.C.7
CAAHEP: V.C.9
CAHIIM: I.B.2
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.08
Topic: Filing Systems

 

  1. How many rules are there for alphabetic filing?
    A.Four
    B. Six
    C. Eight
    D. Ten

There are ten rules for alphabetic filing.

 

ABHES: 4.a
Blooms: Remember
CAAHEP: V.C.10
CAAHEP: V.C.5
CAAHEP: V.C.6
CAAHEP: V.C.7
CAAHEP: V.C.9
CAHIIM: I.B.1
CAHIIM: I.B.2
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.08
Topic: Filing Systems

  1. It is currently estimated that _____ percent of healthcare facilities and _____ percent of physician practices have already implemented EHRs.
    A.60; 40
    B. 70; 30
    C. 80; 50
    D. 90; 60

It is estimated that 80 percent of healthcare facilities and 50 percent of physician practices that have already implemented EHRs.

 

ABHES: 7.b
Blooms: Remember
CAAHEP: V.P.5
CAAHEP: V.P.6
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.03
Topic: Electronic Health Records (EHRs)

 

  1. More than one person ________ use stored data at the same time.
    A.can
    B. cannot
    C. must
    D. must not

More than one person can use stored data at the same time.

 

ABHES: 7.b
Blooms: Remember
CAAHEP: V.P.5
CAAHEP: V.P.6
CAHIIM: I.A.1
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.01
Topic: Computer Usage

  1. Policies and procedures for updating medical personnel and evidence of the training should be placed in the _____.
    A.Compliance manual
    B. Personnel manual
    C. Procedure manual
    D. Rule manual

Policies and procedures for updating medical personnel and evidence of the training should be placed in the compliance manual.

 

ABHES: 4.a
Blooms: Remember
CAAHEP: V.P.8
CAHIIM: I.A.1
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.03
Topic: Electronic Health Records (EHRs)

 

  1. Until electronic health records are fully implemented into the healthcare system, _____ will be needed.
    A.Fax machines
    B. Temporary personnel
    C. File clerks
    D. Scanners

Until electronic health records are fully implemented into the healthcare system, scanners will be needed.

 

ABHES: 7.b
Blooms: Understand
CAAHEP: V.P.5
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.03
Topic: Electronic Health Records (EHRs)

  1. Completely removing electronic data could give the appearance of _____ and is not permissible in many programs.
    A.Cheating
    B. Liability
    C. Fraud
    D. Carelessness

Completely removing electronic data could give the appearance of fraud and is not permissible in many programs.

 

ABHES: 4.a
ABHES: 7.b
Blooms: Remember
CAAHEP: IX.P.7
CAAHEP: V.P.5
CAHIIM: I.A.2
CAHIIM: I.A.3
CAHIIM: I.B.1
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.03
Topic: Electronic Health Records (EHRs)

 

  1. _____ in medical documentation can lead to a vast array of consequences.
    A.Information
    B. Mistakes
    C. Punctuation
    D. Abbreviations

Mistakes in medical documentation can lead to a vast array of consequences.

 

ABHES: 11.b
ABHES: 4.a
ABHES: 7.b
Blooms: Remember
CAAHEP: IX.P.7
CAHIIM: I.A.2
CAHIIM: I.A.3
CAHIIM: I.B.1
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.05
Topic: Technologies for Data Input

  1. Transcriptionists often use _____ to input medical data.
    A.Keyboards
    B. Templates
    C. Pencils
    D. Pens

Transcriptionists use templates to input medical data.

 

ABHES: 7.a
Blooms: Remember
CAAHEP: V.P.3
CAAHEP: V.P.6
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.05
Topic: Technologies for Data Input

 

  1. Which of these abbreviations means “before meals”?
    A.a.c.
    B. b.c.
    C. p.c.
    D. b.m.

The abbreviation a.c. means “before meals”.

 

ABHES: 3.d
Blooms: Remember
CAAHEP: IV.C.11
CAHIIM: I.A.3
CAHIIM: I.A.4
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.04
Topic: Medical Terminology and Abbreviations

  1. Which of these abbreviations means “three times per day”?
    A.q.i.d.
    B. t.i.d.
    C. b.i.d.
    D. q.d.

The abbreviation t.i.d. means “three times per day”.

 

ABHES: 3.d
Blooms: Remember
CAAHEP: IV.C.11
CAHIIM: I.A.3
CAHIIM: I.A.4
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.04
Topic: Medical Terminology and Abbreviations

 

  1. Which of these abbreviations means “after meals”?
    A.a.c.
    B. b.c.
    C. p.c.
    D. q.d.

The abbreviation p.c. means “after meals”.

 

ABHES: 3.d
Blooms: Remember
CAAHEP: IV.C.11
CAHIIM: I.A.3
CAHIIM: I.A.4
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.04
Topic: Medical Terminology and Abbreviations

  1. Lydia works exclusively inputting data into medical records. She seldom takes a break from inputting and works 4 days per week, 10 hours each day. While driving, she notices a change in her distance vision. Which of the following should she do to help ease eye strain while working?
    A.Place her hands and wrists in horizontal alignment.
    B. Regularly focus on distant objects.
    C. Place source documents flat beside her computer.
    D. Frequently rotate her neck and shoulders.

Lydia should regularly focus on distant objects to help ease eye strain while working.

 

ABHES: 7.a
Blooms: Apply
CAAHEP: V.A.2
CAAHEP: V.P.6
CAHIIM: N/A
Difficulty: 3 Hard
Est Time: 0-1 Minute
Learning Outcome: 05.01
Topic: Computer Usage

 

  1. Shannon works for a medical practice that uses the first three letters of the patient’s last name and the date of birth as the patient numbers. When Shannon was filing medical insurance claims, she noticed that a chart note had been made in the wrong chart. The physician sees twin females, and the chart for the wrong twin had been noted. To correct the error, Shannon should:
    A.Eliminate the chart note with correction fluid.
    B. Use a wide, permanent black marker to cross out the chart note.
    C. Place a straight line through the entry, making sure it is still legible; mark it “error” date her correction; and initial the correction.
    D. Place a wavy line through the entry, making sure it is still legible; mark it “error”; date her correction; and initial the correction.

To correct the error, Shannon should place a straight line through the entry, making sure it is still legible; mark it “error”, date her correction; and initial the correction.

 

ABHES: 8.a
Blooms: Apply
CAAHEP: V.P.4
CAHIIM: I.A.2
CAHIIM: I.B.1
Difficulty: 3 Hard
Est Time: 0-1 Minute
Learning Outcome: 05.02
Topic: The Medical Record

  1. When Dr. Crist opened the EHR for her next patient, she was able to quickly view a listing of all of the patients’ current and previously treated medical conditions. Which documentation format does Dr. Crist use?
    A.SOAP
    B. CHEDDAR
    C. DATABASE
    D. POMR

Dr. Crist uses the CHEDDAR format.

 

ABHES: 7.b
ABHES: 8.a
Blooms: Apply
CAAHEP: IX.P.7
CAHIIM: I.A.1
CAHIIM: I.A.2
Difficulty: 2 Medium
Est Time: 0-1 Minute
Learning Outcome: 05.06
Topic: Documentation Formats

 

  1. Which of the following is an acceptable chart notation for “as needed”?
    A.q.4.h
    B. p.r.n.
    C. a.n.
    D. as ndd

The acceptable chart notation for “as needed” is p.r.n.

 

ABHES: 3.d
Blooms: Apply
CAAHEP: IV.C.11
CAHIIM: I.A.4
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.05
Topic: Technologies for Data Input

  1. Entries should be signed and __________.
    A.Time stamped only
    B. Date stamped only
    C. Both signed and date stamped
    D. Verified

All chart notes must be signed and dated.

 

ABHES: 11.b
ABHES: 4.a
ABHES: 4.f
Blooms: Remember
CAAHEP: IX.P.7
CAHIIM: I.B.1
Difficulty: 2 Medium
Est Time: 0-1 Minute
Learning Outcome: 05.03
Topic: Electronic Health Records (EHRs)

 

  1. Excel is an example of what type of software?
    A.Database management software
    B. Graphics application
    C. Word processing program
    D. Spreadsheet program

Spreadsheet applications, such as Excel, are designed to imitate paper bookkeeping ledgers.

 

ABHES: 7.a
Blooms: Remember
CAAHEP: V.P.6
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.01
Topic: Computer Usage

  1. Which of these is used to enter, edit, format, and print documents?
    A.Computer network
    B. Template
    C. Word processing program
    D. File server

A word processing program is used to enter, edit, format, and print documents.

 

ABHES: 7.a
Blooms: Remember
CAAHEP: V.P.6
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.01
Topic: Computer Usage

 

  1. Electronic maintenance of the medical office schedule provides _______________ over paper appointment books.
    A.Advantages
    B. Disadvantages
    C. Difficulties
    D. Inconveniences

Electronic maintenance of the medical office schedule provides advantages over paper appointment books.

 

ABHES: 7.b
Blooms: Remember
CAAHEP: V.C.2
CAAHEP: V.C.3
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.01
Topic: Computer Usage

  1. After a patient encounter, the new electronic medical data should be reviewed and __________ for errors.
    A.Proofread
    B. Verified
    C. Transferred
    D. Templated

After a patient encounter, the new electronic medical data should be reviewed and proofread for error.

 

ABHES: 4.a
ABHES: 7.b
Blooms: Remember
CAAHEP: V.P.5
CAHIIM: I.A.4
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.03
Topic: Electronic Health Records (EHRs)

 

  1. Laws have been passed and large sums of money have been, and are being, invested in the implementation of what?
    A.Electronic signatures
    B. Hospital documentation
    C. Office check in/out policies
    D. Healthcare reform

Laws have been passed and large sums of money have, and are being invested in the implementation of healthcare reform.

 

ABHES: 4.a
Blooms: Remember
CAAHEP: IX.C.13
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.03
Topic: Electronic Health Records (EHRs)

  1. Using the ______ system, it is easy to locate misfiled charts with a quick glance.
    A.Subject filing
    B. Color coding
    C. Numeric coding
    D. Indirect filing

Using the color coding system is easy to locate misfiled charts.

 

ABHES: 4.a
Blooms: Remember
CAAHEP: V.C.10
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.08
Topic: Filing Systems

 

  1. An accession book is used with which type of filing?
    A.Subject filing book
    B. Alphabetic filing
    C. Numeric filing
    D. Compliance filing

An accession book, which is a book of consecutive numbers indicating the next available number to be assigned, is used in numeric filing.

 

ABHES: 8.a
Blooms: Remember
CAAHEP: V.C.10
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.08
Topic: Filing Systems

  1. A technology being used in medical and other offices for data input is ____________.
    A.Voice recognition technology
    B. Transcription
    C. Voice conferencing
    D. Fax machine

A technology being used in medical and other offices for data input is voice-recognition technology.

 

ABHES: 4.a
ABHES: 4.f
Blooms: Remember
CAAHEP: V.P.6
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.05
Topic: Technologies for Data Input

 

  1. Which newer form of communication uses radio waves, rather than wires or cables?
    A.Dial-up communication
    B. Computer network communication
    C. Wireless communication
    D. Supercomputer communication

A newer form of communications systems, referred to as wireless communication, or wireless connectivity, uses radio waves, rather than wires or cables, as the medium for transmitting data.

 

ABHES: 4.a
ABHES: 4.f
Blooms: Remember
CAAHEP: V.P.6
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.01
Topic: Computer Usage

  1. _______________________, or AUP, should be written and included in the office’s policy and procedure manual.
    A.Acceptable use policies
    B. Administrative use policies
    C. Acceptable user profiles
    D. Administrative user profiles

Each office should have an acceptable use policy (AUP) for equipment, time, and other resources, including the computer.

 

ABHES: 11.b
ABHES: 8.a
Blooms: Remember
CAAHEP: V.P.6
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.01
Topic: Computer Usage

 

  1. Which of these includes word processing, graphics, spreadsheet, and database management applications?
    A.Operating system
    B. Application software
    C. Computer mainframe
    D. Screen savers

Application software which includes word processing, graphics, spreadsheet, and database management software, applies the computer’s capabilities to specific applications.

 

ABHES: 7.a
Blooms: Remember
CAAHEP: V.P.6
CAHIIM: N/A
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.01
Topic: Computer Usage

  1. What part of the SOAP note records the physician’s interpretation of the findings?
    A.Subjective
    B. Objective
    C. Assessment
    D. Plan

The assessment in a SOAP record in the physician’s interpretation of the subjective and objective findings.

 

ABHES: 4.a
Blooms: Remember
CAAHEP: V.C.5
CAAHEP: V.P.3
CAHIIM: I.A.2
Difficulty: 1 Easy
Est Time: 0-1 Minute
Learning Outcome: 05.06
Topic: Documentation Formats

 

  1. The CC is located where in the SOAP note?
    A.Subjective
    B. Objective
    C. Assessment
    D. Plan

The CC, or chief complaint, is the patient’s description of the problem or complaint, and it is located in the subjective area of the SOAP note.

 

ABHES: 4.a
Blooms: Remember
CAAHEP: V.C.5
CAAHEP: V.P.3
CAHIIM: I.A.2
CAHIIM: I.A.4
Difficulty: 2 Medium
Est Time: 0-1 Minute
Learning Outcome: 05.06
Topic: Documentation Formats

  1. What are the three essential components of POMR?
    A.SOAP, CHEDDAR, Master Problem List
    B. CHEDDAR, Master Problem List, Initial Plan
    C. Master Problem List, CC, Initial Plan
    D. Database, Master Problem List, Initial Plan

In a POMR, there are three essential components: the Database, the Master Problem List, and the Initial Plan.

 

ABHES: 4.a
Blooms: Remember
CAAHEP: V.C.5
CAAHEP: V.P.3
CAHIIM: I.A.4
Difficulty: 2 Medium
Est Time: 0-1 Minute
Learning Outcome: 05.06
Topic: Documentation Formats

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