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Quiz: Electronic Health Records and Data Entry

By Nancy Kimmel, MSN, FNP / July 2, 2026

Quiz: Electronic Health Records and Data Entry

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Question 1 of 100

1. Question

A CCMA is updating a patient’s record in the EHR. Which of the following is the best example of using a structured data entry method?

Typing a free-text note about the patient's symptoms.
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Selecting the patient's primary complaint from a pre-defined dropdown list.
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Scanning a handwritten note from the provider into the patient's chart.
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Leaving a voicemail for the provider with the patient's update.
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Question 2 of 100

2. Question

A CCMA is working in a busy clinic and is called away from their computer in the middle of documenting a patient encounter. What is the most important action for the CCMA to take before leaving the computer?

Ask another CCMA to finish the documentation.
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Leave the patient's chart open to save time when they return.
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Log out of the EHR system to protect the patient's information.
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Make a note to finish the documentation later.
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Question 3 of 100

3. Question

A new patient is checking in for their first appointment. The CCMA is responsible for entering their information into the EHR. Which of the following pieces of information is considered part of the patient’s demographics?

Their blood pressure reading.
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Their chief complaint.
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Their insurance provider.
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Their allergy to penicillin.
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Question 4 of 100

4. Question

A patient calls to say they have moved to a new address. What is the most appropriate action for the CCMA to take?

Write the new address on a sticky note to give to the provider later.
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Update the patient's demographic information in the EHR immediately.
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Tell the patient to bring proof of their new address to their next appointment.
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Ask the patient to send an email with their new address.
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Question 5 of 100

5. Question

A patient’s EHR contains information from multiple specialists and hospitals. This is an example of the EHR’s ability to provide a…

Comprehensive, longitudinal health record.
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Record of a single clinical encounter.
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Billing statement.
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Provider's personal notes.
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Question 6 of 100

6. Question

A provider asks a CCMA to enter an order for a lab test into the EHR. What part of the EHR would the CCMA use to do this?

The scheduling module.
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The patient demographics section.
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The order entry function.
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The messaging system.
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Question 7 of 100

7. Question

The ‘CARE’ acronym is a useful memory aid for EHR management. What does the ‘A’ in CARE stand for?

Access
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Accuracy
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Authorization
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Accountability
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Question 8 of 100

8. Question

What is the primary purpose of the Health Insurance Portability and Accountability Act (HIPAA) in the context of EHRs?

To set standards for the quality of medical care.
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To ensure that all healthcare providers use the same EHR system.
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To protect the privacy and security of patient health information.
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To regulate the cost of EHR systems.
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Question 9 of 100

9. Question

Which of the following is a key benefit of using an EHR system over paper charts?

EHRs are less expensive to implement and maintain.
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EHRs provide clinical alerts and reminders to improve patient safety.
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EHRs do not require any training to use.
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EHRs are not subject to privacy regulations.
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Question 10 of 100

10. Question

While documenting a patient’s vital signs, a CCMA accidentally enters the wrong respiratory rate. What is the correct procedure for correcting this error in the EHR?

Delete the incorrect entry and enter the correct one.
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Create a new entry and ignore the incorrect one.
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Follow the facility's protocol for making an addendum or correction, which typically involves striking through the error and adding the correct information with an electronic signature.
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Ask the provider to correct the error at the end of the day.
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Question 11 of 100

11. Question

A CCMA is preparing to take a manual blood pressure on an adult patient. What is the first sound they should listen for after inflating the cuff and beginning to release the pressure?

The disappearance of all sound (Phase 5 Korotkoff)
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A soft, swishing sound (Phase 2 Korotkoff)
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A clear, tapping sound (Phase 1 Korotkoff)
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A muffled, blowing sound (Phase 4 Korotkoff)
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Question 12 of 100

12. Question

A CCMA takes a patient’s blood pressure and gets a reading of 185/125 mm Hg. The patient reports a severe headache. What is the most critical next step?

Tell the patient to schedule a follow-up appointment for next week.
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Immediately retake the blood pressure in the other arm.
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Document the reading and have the patient rest for 15 minutes.
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Immediately inform the licensed provider as this is a hypertensive crisis.
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Question 13 of 100

13. Question

A CCMA uses an adult-sized cuff on an obese patient with a large arm circumference. The resulting blood pressure reading is likely to be:

Falsely low
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Falsely high
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Accurate
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Variable and unreliable
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Question 14 of 100

14. Question

A patient arrives for their appointment and mentions they just had a cup of coffee and a cigarette. What is the most appropriate action for the CCMA to take?

Take the blood pressure immediately to save time.
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Ask the patient to wait for at least 30 minutes before taking the reading.
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Use a smaller cuff to compensate for the stimulant effects.
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Record the blood pressure and note that the patient just had caffeine and nicotine.
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Question 15 of 100

15. Question

A patient asks why it’s necessary to rest for 5 minutes in a quiet room before their blood pressure is taken. The CCMA’s best response is:

"It's a clinic policy and we have to follow it."
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"It allows your blood pressure to stabilize to its normal resting level, ensuring we get an accurate reading."
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"It gives me time to get the equipment ready."
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"It doesn't really matter, but it's a good habit."
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Question 16 of 100

16. Question

A patient is seated on the examination table with their legs dangling and their back unsupported. Before taking their blood pressure, the CCMA should instruct the patient to:

Place their feet flat on the floor and sit with their back supported.
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Cross their legs for better stability.
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Hold their arm up without support.
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Lie down on the table.
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Question 17 of 100

17. Question

A patient’s blood pressure is consistently in the 145/95 mm Hg range during several different appointments. This patient would be classified as having:

Normal blood pressure
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Elevated blood pressure
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Hypertension: Stage 1
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Hypertension: Stage 2
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Question 18 of 100

18. Question

A patient’s blood pressure reading is 125/78 mm Hg. According to AHA/ACC guidelines, how should this be classified?

Normal
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Elevated
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Hypertension: Stage 1
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Hypertension: Stage 2
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Question 19 of 100

19. Question

The mnemonic ‘ARM-LEGS’ is a study aid for remembering the steps for accurate blood pressure measurement. What does the ‘L’ stand for?

Listen carefully
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Lower the arm
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Legs uncrossed
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Large cuff size
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Question 20 of 100

20. Question

When measuring blood pressure, the cuff should be deflated at what recommended rate?

1-2 mm Hg per second
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2-3 mm Hg per second
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5-6 mm Hg per second
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As quickly as possible
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Question 21 of 100

21. Question

A bodybuilder is 5’10” and weighs 220 lbs, with a very low body fat percentage. Their calculated BMI is 31.6. What is the most likely reason for this result?

The scale is inaccurate.
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The patient has a high amount of muscle mass.
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The patient is obese.
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The CCMA made a calculation error.
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Question 22 of 100

22. Question

A CCMA is documenting a patient’s weight. In addition to the weight itself, what other information is crucial to include in the medical record?

The brand of the scale used.
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The patient's mood during the measurement.
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The date and time of the measurement.
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The CCMA's personal opinion of the patient's weight.
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Question 23 of 100

23. Question

A CCMA is preparing to weigh a patient who uses a wheelchair and cannot stand. What is the first step the CCMA should take?

Attempt to have the patient stand for a brief moment on the scale.
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Document that the weight could not be obtained.
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Weigh the empty wheelchair and any accessories first.
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Ask a family member for the patient's estimated weight.
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Question 24 of 100

24. Question

A patient has a BMI of 28.5. How would the CCMA classify this patient’s weight status?

Underweight
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Normal weight
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Overweight
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Obesity
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Question 25 of 100

25. Question

A patient is being seen for a routine physical. Their height is 68 inches and their weight is 165 lbs. The CCMA needs to calculate their BMI. Which of the following is the correct calculation?

(165 / 68) * 703
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165 / (68 * 2) * 703
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165 / (68 * 68) * 703
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(165 * 703) / 68
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Question 26 of 100

26. Question

A patient weighs 70 kg and is 1.75 meters tall. What is their BMI?

22.9
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24.5
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20.4
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25.1
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Question 27 of 100

27. Question

A patient’s weight needs to be monitored daily due to congestive heart failure. What is the most important instruction for the CCMA to follow?

Use a different scale each day to ensure accuracy.
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Weigh the patient at the same time each day, on the same scale.
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Allow the patient to wear their shoes for comfort.
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Weigh the patient after they have eaten a full breakfast.
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Question 28 of 100

28. Question

The imperial formula for calculating BMI is: weight (lb) / [height (in)]² x 703. Why is the conversion factor of 703 used?

It accounts for the difference between pounds and kilograms.
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It converts the metric units to imperial units.
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It is a standard medical constant for all calculations.
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It converts the units of measurement to the appropriate BMI units.
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Question 29 of 100

29. Question

When measuring a patient’s height, the patient’s head should be positioned so that the eyes are looking straight ahead. This is known as the:

Neutral position
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Frankfurt plane
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Anatomical position
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Upright position
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Question 30 of 100

30. Question

Which of the following is a potential source of error when measuring a patient’s height?

The patient looking straight ahead.
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The patient keeping their shoes on.
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The patient's back is against the stadiometer.
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The headpiece rests on the crown of the head.
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Question 31 of 100

31. Question

A CCMA is assessing a patient and palpates the artery on the side of the neck, between the trachea and the sternocleidomastoid muscle. Which pulse site is being assessed?

Temporal
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Carotid
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Brachial
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Apical
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Question 32 of 100

32. Question

A CCMA is taking the pulse of a 68-year-old male patient and counts 45 beats in 30 seconds. The rhythm is regular. What is the patient’s pulse rate in bpm, and what is the correct term for this finding?

90 bpm, Tachycardia
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45 bpm, Bradycardia
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90 bpm, Normal
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45 bpm, Normal
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Question 33 of 100

33. Question

A CCMA measures a patient’s pulse and notes that it feels weak and thready. What is the best course of action?

Document the finding as "normal."
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Re-measure the pulse at a different site.
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Inform the patient that their pulse is weak.
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Document the finding and report it to the provider.
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Question 34 of 100

34. Question

A CCMA needs to assess the pulse of a 6-month-old infant. Which site is most appropriate for an accurate measurement?

Radial
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Carotid
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Apical
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Dorsalis Pedis
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Question 35 of 100

35. Question

A patient asks the CCMA why their pulse is taken at the wrist. What is the most appropriate response?

"It's the only place we can feel your pulse."
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"The radial artery at your wrist is easy to access and provides a reliable measurement of your heart rate."
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"It's the hospital's policy to always use the wrist."
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"We use the wrist because it gives a higher reading than other sites."
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Question 36 of 100

36. Question

A patient with a history of an irregular heartbeat comes in for a routine check-up. What is the most accurate way for the CCMA to measure the patient’s pulse rate?

Count the radial pulse for 15 seconds and multiply by 4.
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Count the carotid pulse for 30 seconds and multiply by 2.
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Count the apical pulse for a full 60 seconds.
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Count the radial pulse for 30 seconds and multiply by 2.
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Question 37 of 100

37. Question

A patient’s pulse rate is 110 bpm. Which of the following factors could be a potential cause of this finding?

The patient is an athlete.
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The patient has a fever.
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The patient is taking a beta-blocker medication.
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The patient has been resting for 30 minutes.
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Question 38 of 100

38. Question

When measuring a patient’s radial pulse, which fingers should the CCMA use?

Thumb and index finger
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Index and middle fingers
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Middle and ring fingers
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Any two fingers
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Question 39 of 100

39. Question

Which of the following pulse sites is located behind the knee?

Femoral
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Popliteal
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Brachial
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Dorsalis Pedis
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Question 40 of 100

40. Question

While assessing a patient’s pulse, the CCMA notes that the beats are not evenly spaced. What is the correct term for this finding?

Arrhythmia
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Bradycardia
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Tachycardia
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Bounding
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Question 41 of 100

41. Question

A 2-year-old toddler is in the clinic for a well-child visit. Which of the following respiratory rates would be considered within the normal range for this child?

16 breaths per minute
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28 breaths per minute
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45 breaths per minute
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55 breaths per minute
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Question 42 of 100

42. Question

A medical assistant counts 9 breaths in 30 seconds on an adult patient with a regular breathing pattern. What is the calculated respiratory rate per minute?

9 breaths/minute
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18 breaths/minute
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27 breaths/minute
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36 breaths/minute
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Question 43 of 100

43. Question

A medical assistant is attempting to get a pulse oximetry reading on an elderly patient with very cold hands and poor circulation. The oximeter is not providing a consistent reading. What is the best next step?

Document that the equipment is malfunctioning.
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Try using an earlobe or a different, warmer finger.
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Ask the patient to hold their breath for 10 seconds.
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Record the last number that flashed on the screen.
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Question 44 of 100

44. Question

A medical assistant is measuring vital signs on a 45-year-old patient. The respiratory rate is counted as 10 breaths per minute. What is the correct term for this finding?

Eupnea
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Tachypnea
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Bradypnea
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Apnea
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Question 45 of 100

45. Question

A patient is brought to the clinic with shortness of breath. The medical assistant notes their breathing is very fast and shallow. The respiratory rate is 32 breaths per minute. This patient is exhibiting signs of:

Eupnea
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Bradypnea
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Apnea
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Tachypnea
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Question 46 of 100

46. Question

A patient is wearing dark blue nail polish. Why might this be a problem for obtaining a vital sign measurement?

It can interfere with an accurate blood pressure reading.
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It can absorb the light from a pulse oximeter, causing a false reading.
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It can artificially lower the patient's measured temperature.
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It has no effect on any vital sign measurements.
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Question 47 of 100

47. Question

A patient’s pulse oximetry reading is 96%. How should the medical assistant interpret this finding?

It indicates severe hypoxemia.
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It is a critically low value requiring immediate intervention.
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It is a normal oxygen saturation level.
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The reading is likely inaccurate due to patient movement.
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Question 48 of 100

48. Question

When measuring a patient’s respiratory rate, the medical assistant should observe the rise and fall of the chest for how long to ensure the most accurate result?

15 seconds and multiply by 4
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30 seconds and multiply by 2
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60 seconds
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10 seconds and multiply by 6
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Question 49 of 100

49. Question

Which of the following correctly describes the physiological process measured by pulse oximetry?

The concentration of carbon dioxide in the venous blood.
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The electrical activity of the heart during contraction.
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The percentage of hemoglobin that is saturated with oxygen.
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The pressure of the blood against the arterial walls.
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Question 50 of 100

50. Question

While assessing respirations, the medical assistant also notes the rhythm and depth of breathing. What is the best description for normal, effortless breathing?

Shallow and irregular
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Deep and gasping
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Regular and unlabored
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Rapid and noisy
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Question 51 of 100

51. Question

A CCMA needs to select a thermometer for a newborn infant. Which method is most commonly recommended for its accuracy in this age group?

Oral
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Axillary
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Tympanic
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Rectal
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Question 52 of 100

52. Question

A medical assistant is preparing to take a temperature on a 6-year-old child who has been crying and is uncooperative. Which of the following methods would be the most appropriate and least invasive?

Oral
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Rectal
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Temporal Artery
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Tympanic
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Question 53 of 100

53. Question

A medical assistant is taking a tympanic temperature on a 45-year-old adult. What is the correct procedure for straightening the ear canal?

Pull the pinna down and back.
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Pull the pinna straight back.
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Pull the pinna up and back.
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No manipulation of the pinna is needed.
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Question 54 of 100

54. Question

A medical assistant obtains a tympanic temperature reading of 97.2°F on an adult patient who complains of chills. The CCMA’s next step should be to:

Document the reading as the final temperature.
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Check the ear for cerumen and reposition the probe to retake the temperature.
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Immediately switch to a rectal thermometer to confirm the low reading.
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Tell the patient their temperature is normal and the chills are not related.
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Question 55 of 100

55. Question

A patient asks why the medical assistant is scanning a thermometer across their forehead. The CCMA’s best response is:

"This measures the heat coming from the main artery in your head to check your temperature."
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"It's a new device that estimates your temperature based on skin warmth."
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"This is the quickest way to see if you have a fever without touching you."
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"This method is more accurate than taking your temperature in your ear."
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Question 56 of 100

56. Question

A patient’s oral temperature is 99.8°F. The patient states they smoked a cigarette about 10 minutes before the appointment. How should the medical assistant interpret this situation?

The temperature is accurate and indicates a low-grade fever.
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The reading may be falsely elevated; the temperature should be retaken in 20 minutes.
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The reading may be falsely low; the temperature should be retaken rectally.
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The temperature is within the normal range and requires no further action.
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Question 57 of 100

57. Question

A patient’s rectal temperature is 101.2°F. The medical assistant recognizes this is approximately equivalent to what oral temperature?

100.2°F
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101.2°F
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102.2°F
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99.2°F
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Question 58 of 100

58. Question

When comparing temperature measurement methods, which site reflects the body’s core temperature most accurately but is also the most invasive?

Oral
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Tympanic
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Temporal
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Rectal
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Question 59 of 100

59. Question

When taking an oral temperature, where should the probe of the digital thermometer be placed to ensure an accurate reading?

On top of the tongue
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In the posterior sublingual pocket
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Against the inside of the cheek
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Just behind the front teeth
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Question 60 of 100

60. Question

Which of the following conditions is a contraindication for taking a rectal temperature?

High blood pressure
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Recent consumption of hot beverages
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Presence of significant cerumen
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Recent rectal surgery
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Question 61 of 100

61. Question

A CCMA is interviewing a new patient who is hesitant to discuss their use of illicit drugs. Which of the following actions by the CCMA is most appropriate?

Insist that the patient answer the question for their own safety.
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Document "Patient refused to answer" and move on to the next question.
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Reassure the patient about confidentiality and explain why the information is important for their care.
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Skip the question and ask the provider to address it later.
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Question 62 of 100

62. Question

A patient is providing their health history and mentions they take “a little white pill” for their heart. What is the CCMA’s most appropriate next step?

Document "patient takes a little white pill for the heart."
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Ask the patient to bring the medication bottle to the next appointment.
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Ask clarifying questions, such as the medication's name, dosage, and frequency.
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Look up common heart medications to try and identify the pill.
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Question 63 of 100

63. Question

A patient reports that their mother and sister both have a history of breast cancer. This information is documented in which section of the health history?

Past Medical History
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Social History
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Family History
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Review of Systems
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Question 64 of 100

64. Question

A patient states they are here for a “follow-up on their blood pressure.” In which section of the health history would the CCMA document this?

History of Present Illness
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Chief Complaint
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Past Medical History
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Review of Systems
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Question 65 of 100

65. Question

A patient with a chief complaint of “sore throat” also mentions experiencing mild joint pain and a rash during the Review of Systems. How does this additional information impact the provider’s assessment?

It is irrelevant to the chief complaint and should be ignored.
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It suggests the patient has multiple, unrelated health problems.
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It may indicate a systemic illness where the sore throat is just one of many symptoms.
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It confirms the diagnosis of a simple viral pharyngitis.
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Question 66 of 100

66. Question

A patient’s social history reveals they work the night shift at a factory and have difficulty sleeping during the day. How might this information be clinically relevant to their complaint of chronic fatigue?

It has no clinical relevance.
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It suggests a genetic predisposition to fatigue.
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It is a direct cause of their chronic fatigue due to disruption of the circadian rhythm.
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It is a potential contributing factor to their fatigue and should be explored further.
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Question 67 of 100

67. Question

The mnemonic OLDCARTS is used to gather a detailed account of which component of the health history?

Past Medical History
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Review of Systems
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History of Present Illness
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Social History
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Question 68 of 100

68. Question

The Review of Systems (ROS) is best described as:

A detailed exploration of the chief complaint.
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A summary of the patient's past surgeries and hospitalizations.
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A head-to-toe inventory of symptoms to uncover other health issues.
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An assessment of the patient's lifestyle and habits.
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Question 69 of 100

69. Question

When exploring the History of Present Illness (HPI), which of the following is the most appropriate question to ask about the “character” of a patient’s pain?

"When did the pain start?"
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"On a scale of 1 to 10, how would you rate your pain?"
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"Can you describe the pain? Is it sharp, dull, or throbbing?"
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"Does the pain move to any other part of your body?"
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Question 70 of 100

70. Question

Which of the following is an example of a “leading question” that a CCMA should avoid asking?

"What brings you in today?"
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"You haven't had any fever, have you?"
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"Can you tell me more about the pain?"
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"On a scale of 1-10, what is your pain level?"
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Question 71 of 100

71. Question

A 45-year-old male patient describes his pain as a “burning sensation” in his lower back. Which component of the PQRST pain assessment does this information represent?

Provocation/Palliation
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Quality
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Region/Radiation
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Severity
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Question 72 of 100

72. Question

A CCMA asks a patient, “Does the pain travel to any other part of your body?” This question is assessing which component of the OLDCARTS mnemonic?

Onset
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Location
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Radiation
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Treatment
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Question 73 of 100

73. Question

A CCMA is assessing a non-verbal patient who is grimacing and guarding their abdomen. Which pain assessment tool would be most appropriate to use in this situation?

Numeric Rating Scale (NRS)
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Wong-Baker FACES Pain Rating Scale
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FLACC Scale
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PQRST Mnemonic
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Question 74 of 100

74. Question

A CCMA is documenting a patient’s pain assessment. The patient states that the pain started two days ago. Under which component of the OLDCARTS mnemonic would this be documented?

Onset
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Location
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Duration
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Characteristics
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Question 75 of 100

75. Question

A patient describes their pain as “intermittent.” This relates to which aspect of the pain assessment?

Quality
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Severity
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Timing
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Location
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Question 76 of 100

76. Question

A patient reports that their knee pain is worse when they walk up stairs and feels better when they rest. This information would be documented under which component of the PQRST assessment?

Provocation/Palliation
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Quality
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Region/Radiation
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Timing
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Question 77 of 100

77. Question

A patient with a broken leg rates their pain as a 9 on a 0-10 numeric scale. This is an example of which part of the pain assessment?

Quality
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Region
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Severity
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Timing
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Question 78 of 100

78. Question

The “R” in the PQRST pain assessment mnemonic stands for:

Rating
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Relief
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Region/Radiation
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Response
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Question 79 of 100

79. Question

When assessing the pain of a 4-year-old child, which pain scale is most appropriate?

Numeric Rating Scale (NRS)
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Wong-Baker FACES Pain Rating Scale
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FLACC Scale
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Verbal Descriptor Scale
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Question 80 of 100

80. Question

Which of the following is NOT a component of the FLACC scale?

Face
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Legs
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Agitation
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Cry
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Question 81 of 100

81. Question

A 17-year-old patient arrives alone for a routine sports physical. When presenting the Consent to Treat form for signature, the CCMA should:

Allow the 17-year-old to sign the form.
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Ask the patient to have their parent/guardian sign it when they are picked up.
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Verify if a consent form signed by a parent or legal guardian is already on file.
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Tell the patient the doctor cannot see them without a parent present.
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Question 82 of 100

82. Question

A new patient arrives at the clinic for their appointment. What is the first and most critical step a CCMA should take to ensure patient safety?

Ask for their insurance card.
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Ask them to sign the HIPAA form.
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Ask them to state their full name and date of birth.
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Hand them a clipboard with new patient paperwork.
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Question 83 of 100

83. Question

A patient calls to schedule an appointment and says they have a new insurance plan. To prepare for their check-in, the CCMA should ask for all the following information over the phone EXCEPT:

The name of the insurance company.
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The patient's policy and group numbers.
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The subscriber's name and date of birth.
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The patient's full medical history.
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Question 84 of 100

84. Question

A patient in the waiting room complains loudly about the long wait time, causing a disturbance. The CCMA at the front desk has already checked the patient in. What is the most professional and analytical response?

Ignore the patient, as they are already checked in.
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Tell the patient that everyone has to wait and their turn will come.
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Quietly and privately acknowledge the patient's frustration, apologize for the delay, and give them an updated, realistic estimate of the wait time.
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Announce to the waiting room that the doctor is running behind schedule.
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Question 85 of 100

85. Question

A patient is handed a HIPAA Notice of Privacy Practices form. They ask, “What am I signing here?” What is the best response by the CCMA?

"It's just a standard form we have everyone sign."
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"You're signing to agree to all of our clinic's policies."
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"This form acknowledges that you have been informed of how your health information is protected and used."
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"This gives us permission to share your medical records with anyone we need to."
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Question 86 of 100

86. Question

A patient presents an insurance card at check-in. The CCMA’s next step should be to:

Assume the insurance is active and proceed.
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Make a photocopy of the card for the file.
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Verify eligibility and coverage through an online portal or by phone.
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Collect the co-payment listed on the card.
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Question 87 of 100

87. Question

A returning patient mentions they have recently changed their home address. What is the CCMA’s most appropriate action?

Tell them to inform the doctor during the exam.
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Make a mental note to update it later.
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Update the demographic information in the patient's electronic health record (EHR) immediately.
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Ask them to fill out a completely new patient registration form.
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Question 88 of 100

88. Question

During patient registration, a CCMA notices that a patient’s medical history form is incomplete. The patient has left the section on current medications blank. What is the most appropriate next step?

Assume the patient is not taking any medications.
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Ask the nurse to complete the form with the patient.
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Politely ask the patient, "I see the medication section is blank. Can you confirm for me that you are not currently taking any medications, vitamins, or supplements?"
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Leave the form for the physician to review.
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Question 89 of 100

89. Question

The primary purpose of the “Memory Anchor” mnemonic GREET (Greet, Request/verify, Ensure forms, Examine card, Thank) is to:

Provide a script for CCMAs to follow exactly with every patient.
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Help CCMAs remember the critical sequence of the check-in process for consistency and accuracy.
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Fulfill a legal requirement for patient registration.
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Serve as a checklist for billing purposes.
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Question 90 of 100

90. Question

When reviewing a completed Patient Registration Form, the CCMA notices the patient has listed their work phone number but not a personal cell phone number. Which action demonstrates the highest level of attention to detail?

Leaving it as is, since a phone number is provided.
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Asking the patient if they have a preferred contact number for receiving potentially sensitive health information.
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Calling the work number to make sure it is correct.
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Assuming the work number is the preferred contact method.
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Question 91 of 100

91. Question

A 45-year-old patient presents for a follow-up visit for their hypertension. The CCMA takes their blood pressure and finds it to be 150/95 mmHg. The provider reviews the reading and decides to increase the patient’s lisinopril dosage. The decision to increase the medication belongs in which part of the SOAP note?

Subjective
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Objective
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Assessment
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Plan
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Question 92 of 100

92. Question

A CCMA is gathering the History of Present Illness (HPI) from a patient with a cough. Which of the following questions aligns with the “Characterization” component of the OLDCARTS mnemonic?

"When did your cough start?"
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"Is there anything that makes your cough better or worse?"
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"Can you describe what the cough feels like? Is it dry or are you coughing anything up?"
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"On a scale of 1 to 10, how severe is your cough?"
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Question 93 of 100

93. Question

A CCMA is preparing a patient’s chart. The patient has a history of diabetes, had an appendectomy in 2015, and smokes half a pack of cigarettes per day. This information should be placed in which subsection of the SOAP note?

Chief Complaint (CC)
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History of Present Illness (HPI)
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Past Medical, Family, and Social History (PFSH)
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Review of Systems (ROS)
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Question 94 of 100

94. Question

A patient is seen for a sore throat. The CCMA documents the chief complaint. The provider performs a physical exam and notes redness and swelling of the pharynx. A rapid strep test is performed and is positive. The provider diagnoses the patient with streptococcal pharyngitis and prescribes an antibiotic. Which of the following represents the ‘Assessment’ portion of this encounter?

Sore throat
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Positive rapid strep test
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Streptococcal pharyngitis
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Prescription for antibiotics
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Question 95 of 100

95. Question

A patient states, “I have a sharp pain in my right lower abdomen that started yesterday.” In which section of the SOAP note should this information be documented?

Objective
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Assessment
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Subjective
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Plan
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Question 96 of 100

96. Question

A patient’s chart notes that their lungs are “clear to auscultation bilaterally.” This is an example of what kind of information?

Subjective
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Objective
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Assessment
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Plan
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Question 97 of 100

97. Question

A provider’s note says, “Rule out myocardial infarction.” This statement is an example of a:

Chief Complaint
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Differential Diagnosis
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Plan
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Subjective complaint
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Question 98 of 100

98. Question

The provider’s diagnosis of “acute otitis media” would be documented in which section of the SOAP note?

Subjective
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Objective
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Assessment
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Plan
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Question 99 of 100

99. Question

Which of the following is an example of Objective data?

The patient's mother has a history of high blood pressure.
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The patient complains of a headache.
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The patient's temperature is 101.4°F.
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The provider recommends drinking more fluids.
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Question 100 of 100

100. Question

Why is accurate medical documentation, such as the SOAP note, legally important?

It helps the medical assistant practice outside their scope.
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It provides a legal record of the care provided and can protect the healthcare facility and staff in case of a lawsuit.
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It is the primary method for communicating with the patient's family.
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It is only for billing purposes and has no legal standing.
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