#1
Which document contains a patient's medical history, current health conditions, and medications?
Prescription
Insurance card
Medical record
Appointment schedule
#2
What is the purpose of the 'CC' in a medical history?
Critical Care
Chief Complaint
Clinical Consultation
Coding Classification
#3
What does 'E&M' stand for in medical documentation and billing?
Examination and Monitoring
Evaluation and Management
Emergency and Medicine
Endoscopy and Microbiology
#4
What is the purpose of the 'DNR' order in medical documentation?
Do Not Reappoint
Do Not Resuscitate
Documented Nursing Review
Daily Nutritional Regimen
#5
What does the acronym 'HIT' stand for in the context of healthcare documentation?
Highly Integrated Technology
Health Information Technology
Hospital Imaging Techniques
Human Interaction Training
#6
What does the term 'SOAP' stand for in medical documentation?
Symptoms, Observations, Analysis, Plan
Subjective, Objective, Assessment, Plan
Science, Observation, Assessment, Prescription
Systematic, Objective, Analysis, Procedure
#7
In medical coding, what does the acronym 'ICD' stand for?
International Classification of Diseases
Internal Coding Documentation
Integrated Clinical Diagnosis
Inpatient Care Directory
#8
Which document serves as a legal agreement outlining a patient's treatment choices in case they become unable to communicate their wishes?
Insurance Policy
Patient Registration Form
Advance Directive
Informed Consent
#9
What does 'EMR' stand for in the context of medical documentation?
Emergency Medical Response
Electronic Medical Record
Effective Medical Reporting
Expedited Medical Review
#10
Which section of a medical note typically includes the physician's findings from a physical examination?
ROS - Review of Systems
HPI - History of Present Illness
PE - Physical Examination
A&P - Assessment and Plan
#11
In medical terminology, what does 'Rx' represent?
Right X-ray
Radiation Exposure
Prescription
Rehabilitation Exercise
#12
Which medical documentation format is often used for progress notes, organized under Subjective, Objective, Assessment, and Plan sections?
FISH - Findings, Interventions, Symptoms, History
SOAP - Subjective, Objective, Assessment, Plan
MAP - Medical Assessment Protocol
PQRST - Pain, Quality, Region, Severity, Timing
#13
What is the purpose of the 'HPI' section in a medical note?
History of Present Illness
Hospital Patient Information
Health Provider Inquiry
High Priority Incident
#14
Which standard is commonly used for electronic health records (EHR) interoperability?
#15
In medical billing, what is the purpose of the 'CPT' code?
Clinical Procedure Time
Current Procedural Terminology
Certified Patient Treatment
Coding and Payment Tracker
#16
What is the role of 'HIPAA' in healthcare documentation?
Health Insurance Portability and Accountability Act
Healthcare Information Privacy and Assurance Act
Highly Integrated Patient Authorization Agreement
Hazard Identification and Patient Accessibility Act
#17
What is the primary purpose of a 'MIPS' score in healthcare documentation?
Measuring Inpatient Performance Standards
Monitoring Infection Prevention Strategies
Merit-based Incentive Payment System
Medical Information Privacy and Security
#18
Which organization oversees the development and maintenance of the 'SNOMED CT' clinical terminology system?
WHO - World Health Organization
CMS - Centers for Medicare & Medicaid Services
IHTSDO - International Health Terminology Standards Development Organization
AMA - American Medical Association
#19
What does 'OCR' stand for in the context of medical documentation?
Optical Character Recognition
On-Call Radiology
Orthopedic Consultation Report
Outpatient Care Record