Medical exam

Student ID: 22329877

Exam: 039844RR - Medical Records and Reports

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Questions 1 to 20: Select the best answer to each question. Note that a question and its answers may be split across a page break, so be sure that you have seen the entire question and all the answers before choosing an answer.

1. When preparing a medical history, CC refers to A. chief concern.

B. courtesy copy.

C. concern/complain.

D. chief complaint.

2. While reading an H&P report, you notice the word "unremarkable" under the subtopic "Pelvic." This means the physician is saying the findings are A. abnormal.

B. significant.

C. normal.

D. dangerous.

3. Which report is dictated in the following order: Preoperative diagnosis(es), Postoperative diagnosis(es), Name of procedure(s), Name of surgeon(s), Name of assistants(s)? A. H&P

B. Operative report

C. Radiology report

D. Discharge summary

4. What does the "O" in the SOAP method refer to? A. Objective

B. OBGYN

C. Obstetrician

D. Object

5. Which of the Basic Four reports takes priority in transcription? A. discharge summary

B. operative report

C. H&P

D. consultation report

6. Which type of allergy are MTs often directed to boldface, underline, or type in all capital letters? A. Drug

B. Food

C. Animal

D. Seasonal

7. If the H&P is dictated more than _______ days before a procedure, it must be updated by the physician. A. 60

B. 90

C. 7

D. 30

8. Where in a discharge summary would the following be transcribed? "Predelivery H&H of 12.4 and 36.2 respectively. Platelets 221. Electrolytes normal." A. Hospital Course and Treatment

B. Laboratory Data

C. Surgical Procedures

D. Physical Examination

9. Where in a physical examination report would the following be transcribed? “Range of motion is within normal limits.” A. Extremities

B. Neurological

C. HEENT

D. Pelvic

10. Dr. Jones dictates the following: “No itching or scaling, but the patient says that she has had quote severe skin allergies in the past year end quote.” Why would Dr. Jones add the words "quote" and "end quote" to this dictation? A. This indicates the doctor doesn't agree with the patient's self-assessment.

B. This indicates the doctor believes the condition in quotes to be a significant health threat.

C. This indicates the doctor is unsure about the condition or problem and adds quotes as a way of indicating that uncertainty.

D. This indicates the patient has made a decision about a problem that may or may not be correct.

11. When a patient dies in the hospital or within 24 hours of discharge from the hospital, the next of kin can request a/an _______ to determine cause of death. A. pathology report

B. autopsy

C. physical exam

D. CT scan

12. Emergency department chart notes are transcribed A. within 24 hours of being dictated.

B. within 5 business days of being dictated.

C. on a STAT (immediate) basis.

D. Within 30 days of being dictated.

13. Sig. is the abbreviation for A. respirations.

B. immediately.

C. vital signs.

D. directions.

14. The best way to attest that medical records were true and correct at the time they were written is the A. patient's signature or initials at the end of teach typed note.

B. physician's signature or initials at the end of each typed note.

C. medical transcriptionist's signature or initials at the end of each typed note.

D. hospital's official stamp at the end of the medical record.

15. Aortograms, barium enemas, cystograms, and venograms are all types of _______ reports. A. radiology

B. consultation

C. pathology

D. operative

16. The spelling of different types of contrast media can be found in the back of the A. Physician's Drug Reference (PDR).

B. American Drug Index.

C. Clinical Pharmacology.

D. Saunders Pharmaceutical Word Book.

17. A/an _______ report should be dictated to the medical record immediately after any surgery. A. H&P

B. operative

C. discharge

D. consultation

18. The abbreviation R/O is short for A. rate/output.

B. rule out.

C. respiratory observation.

D. rate of.

19. During the physical examination, listening to body sounds is known as A. percussion.

End of exam

B. palpation.

C. inspection.

D. auscultation.

20. What type of medical decision making is considered self-limited or used for a minor problem? A. Straightforward

B. Moderate complexity

C. High complexity

D. Low complexity