Chapter 1: The Medical Record
Mrs. Dasalla
1. What information is contained in the medical record?
Health history, results of the physical examination, laboratory reports and progress
2. What is the function of the medical record? To provide information for making
decisions about the patient’s care, to document the patient’s progress and to serve as
a legal document.
3. The purpose of HIPAA is to: Provide patients with more control over the use and
disclosure of their health information.
4. The patient registration record consists of: demographic and billing information
5. What is included in the patient registration record? D.O.B., employer, patient’s
insurance carrier information and other demographics.
6. What provides subjective data about a patient to assist the physician in arriving at a
diagnosis? Health history
7. A narrative report of an opinion about a patient’s condition by a practitioner other than
the attending physician is known as a: Consultation report
8. A report of the analysis of body specimens is known as a: Laboratory report
9. What are some examples of a diagnostic report? Spirometry report, colonoscopy
report, radiology report, EKG report
10. What can help a patient with a disability learn new skills to perform the activities of daily
living? Occupational therapy
11. What term is used to describe a patient who has been admitted to the hospital for at least
one overnight stay? Inpatient
12. Conclusions drawn from an interpretation of data are known as: Medical impressions
13. What is included in an operative report? Name of the surgical procedure, description
of the procedure used during the surgery and postoperative diagnosis
14. Which reports consists of an account of the significant events of a patient’s
hospitalization? Discharge summary report
15. Which reports consists of a macroscopic and microscopic description of tissue removed
during surgery? Pathology report
16. A consent to treat form is required for: invasive/surgical procedures
17. What must be included in informed consent? An explanation of the risks involved with
the procedure, any alternative treatments or procedures available, the prognosis
and the purpose of the recommended procedure.
18. 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
19. When do we require the completion of a release of medical information form? When a
patient transfers their records to a new physician
20. What is included in the release of medical information form? The specific information
to be released, the need for the information, the patient’s signature and the
expiration date of the release form.
21. What can be performed by an electronic medical record software program? Creation,
storage, editing and retrieval of a medical record.
In a source-oriented record, a radiology report is filed under which chart dividers?
With reverse chronological order, the most recent document is: Placed in the front of
the other documents
The acronym for the format used to organize POR progress notes is: SOAP
What is the chief complaint? The symptom causing the patient the most trouble
What is the correct method for recording the chief complaint? Problem, duration.
Example: “Coughing up phlegm, pain in chest for past 3 days.”
What is the medical history? The patient’s previous diseases, injuries and operations
What are some examples of a familial disease? Diabetes, Hypertension, Breast Cancer
Why is the social history about the patient important? The lifestyle of the patient can
affect their condition
What is the ROS? Review of the Systems-systematic review of each body system
What term is used to describe the process of making written entries about a patient in the
medical record? Charting
Black ink should be used when recording in the patient’s chart to: Provide a permanent
What must be done when charting? Begin each new entry on a separate line, begin
each phrase with a capital letter, include the date and time with each entry
A procedure should be charted immediately after being performed to: Avoid forgetting
certain aspects of the procedure
What is the correct way to sign a charting entry? Your first initial, last name, followed
by your credentials
Example: B. Smith, CMA
Why should a recording in the medical record never be erased or obliterated? Credibility
is reduced if the physician is later involved in a litigation
The purpose of progress notes is to: Update the medical record with new patient
What is a symptom? Any change in the body or its functioning that indicates disease
What is an objective symptom? One that can be observed by another person
What is an example of a subjective symptom? Pain, headache, dizziness.