Clinical Documentation
Exam Answer Key
Course Introduction
Clinical Documentation is a comprehensive course focused on the principles and practices of recording patient care information accurately and securely within healthcare settings. Students will learn the critical role of clinical documentation in communicating patient assessments, interventions, and outcomes among healthcare professionals, ensuring patient safety, and supporting legal, regulatory, and billing requirements. The course covers proper documentation techniques, the use of electronic health records (EHRs), privacy and confidentiality standards such as HIPAA, and strategies to enhance clarity, accuracy, and completeness in patient records. Through case studies and practical exercises, students will develop the skills to maintain high standards of clinical documentation essential for quality patient care and healthcare operations.
Recommended Textbook
Medical Terminology A Living Language 6th Edition by Bonnie F. Fremgen
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15 Chapters
2592 Verified Questions
2592 Flashcards
Source URL: https://quizplus.com/study-set/978
Page 2
Chapter 1: Introduction to Medical Terminology
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177 Verified Questions
177 Flashcards
Source URL: https://quizplus.com/quiz/19297
Sample Questions
Q1) The results from the lab and X-rays are given in a Diagnostic Report.
A)True
B)False Answer: True
Q2) The suffixes -rrhea and -rrhexis have the same meaning. A)True
B)False Answer: False
Q3) A suffix that means instrument for viewing is ________. Answer: -scope
Q4) The combining form that means life is ________. Answer: bi/o
Q5) A prefix that means outside of is ________. Answer: extra-
Q6) The prefix brady- means fast.
A)True
B)False Answer: False
Q7) A prefix that means against is ________. Answer: anti-
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Chapter 2: Body Organization
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177 Verified Questions
177 Flashcards
Source URL: https://quizplus.com/quiz/19298
Sample Questions
Q1) Which plane divides the body into front and back portions?
A)sagittal
B)frontal
C)transverse
D)median Answer: B
Q2) Which of the following cavities is not a ventral cavity?
A)abdominal
B)spinal
C)thoracic
D)pelvic Answer: B
Q3) The term deep means farther away from the surface of the body.
A)True
B)False
Answer: True
Q4) Gynecology is the branch of medicine that treats the male reproductive tract.
A)True
B)False
Answer: False
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Chapter 3: Integumentary System
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177 Verified Questions
177 Flashcards
Source URL: https://quizplus.com/quiz/19299
Sample Questions
Q1) Which term means surgical removal of wrinkles?
A)rhytidotomy
B)rhytidoplasty
C)rhytidectomy
D)rhytidostomy
Answer: C
Q2) A pustule is a raised spot containing pus.
A)True
B)False
Answer: True
Q3) Which procedure is commonly referred to as a chemical peel?
A)curettage
B)liposuction
C)dermabrasion
D)chemabrasion
Answer: D
Q4) A vesicle is commonly called a blister.
A)True
B)False
Answer: True
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Chapter 4: Musculoskeletal System
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177 Verified Questions
177 Flashcards
Source URL: https://quizplus.com/quiz/19300
Sample Questions
Q1) Muscular dystrophy is an inherited disease.
A)True
B)False
Q2) A medical term that means cutting into a bone is ________.
Q3) Which type of fracture occurs because the bone is diseased or weakened?
A)stress fracture
B)pathologic fracture
C)spiral fracture
D)oblique fracture
Q4) Widespread aching and pain in the muscles and soft tissue is called:
A)carpal tunnel syndrome
B)fibromyalgia
C)repetitive motion disorder
D)polymyositis
Q5) A medical term that means lack of tone is ________.
Q6) The combining form that means movement is ________.
Q7) Myelography is the process of recording the bone marrow.
A)True
B)False
Q8) A medical term that means fusion of a joint is ________.
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Chapter 5: Cardiovascular System
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177 Verified Questions
177 Flashcards
Source URL: https://quizplus.com/quiz/19301
Sample Questions
Q1) A heart specialist would be called a:
A)cardiologist
B)phlebotomist
C)coronologist
D)hemangiologist
Q2) A medical term that means pertaining to a valve is ________.
Q3) The superior vena cava carries blood away from the heart.
A)True
B)False
Q4) Ligation and stripping is a surgical treatment for varicose veins.
A)True
B)False
Q5) A medical term that means pertaining to between ventricles is ________.
Q6) Which structure of the conduction system was formerly called the bundle of His?
A)bundle branches
B)atrioventricular bundle
C)atrioventricular node
D)atrioventricular septum
Q7) A combining form that means valve is ________.
Q8) A medical term that means surgical repair of a valve is ________.
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Chapter 6: Blood and the Lymphatic and Immune Systems
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177 Verified Questions
177 Flashcards
Source URL: https://quizplus.com/quiz/19302
Sample Questions
Q1) Which of the following statements regarding blood types is not true?
A)Type A blood makes antibodies against Type B blood.
B)Type O blood makes antibodies only against Type AB blood.
C)Type B blood makes antibodies against Type A blood.
D)Type AB blood does not make antibodies.
Q2) Mononucleosis is caused by the Epstein-Barr virus.
A)True
B)False
Q3) The combining form that means tonsils is ________.
Q4) Opportunistic infections affect patients with anemia.
A)True
B)False
Q5) Both the ELISA and the Western blot tests are used to detect the presence of antibodies against the AIDS virus.
A)True
B)False
Q6) Leukemia is an inherited condition in which blood fails to clot.
A)True
B)False
Q7) A combining form that means blood is ________.
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Chapter 7: Respiratory System
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177 Verified Questions
177 Flashcards
Source URL: https://quizplus.com/quiz/19303
Sample Questions
Q1) Which of the following statements regarding bronchial tubes is not true?
A)Each bronchus is surrounded by pulmonary capillaries.
B)Gas exchange occurs across the respiratory membrane.
C)The trachea splits into a left and right main bronchus.
D)Alveoli are located at the tips of bronchioles.
Q2) Which of the following is not an organ of the respiratory system?
A)lungs
B)esophagus
C)trachea
D)nasal cavity
Q3) Bronchoscopy is a procedure to examine inside the voice box with a scope.
A)True
B)False
Q4) The suffix that means voice is ________.
Q5) Which abbreviation stands for a diagnostic laboratory test?
A)CPR
B)ENT
C)ARDS
D)ABGs
Q6) A medical term that means surgical repair of bronchus is ________.
Page 9
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Chapter 8: Digestive System
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177 Verified Questions
177 Flashcards
Source URL: https://quizplus.com/quiz/19304
Sample Questions
Q1) The combining form that means abdomen is ________.
Q2) Which of the following procedures provides the patient with intravenous nutrition?
A)total parenteral nutrition
B)gavage
C)nasogastric intubation
D)lavage
Q3) Which abbreviation stands for a lab test?
A)n&v
B)IBS
C)UGI
D)O&P
Q4) The ________ of the small intestine receives food from the stomach.
A)cecum
B)jejunum
C)ileum
D)duodenum
Q5) Gastric stapling is used to treat PUD.
A)True
B)False
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Chapter 9: Urinary System
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177 Verified Questions
177 Flashcards
Source URL: https://quizplus.com/quiz/19305
Sample Questions
Q1) The kidneys are in the retroperitoneal location.
A)True
B)False
Q2) A ________ is the narrowing of a passageway in the urinary system.
A)stricture
B)catheter
C)nephrolith
D)calculus
Q3) A medical term that means X-ray record of the kidney is ________.
Q4) Which is not an organ of the urinary system?
A)kidney
B)bladder
C)urethra
D)liver
Q5) Which term means surgical fixation of the bladder?
A)cystotomy
B)cystoplasty
C)cystectomy
D)cystopexy
Q6) The combining form that means renal pelvis is ________.
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Chapter 10: Reproductive System
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177 Verified Questions
177 Flashcards
Source URL: https://quizplus.com/quiz/19306
Sample Questions
Q1) A combining form that means female is ________.
Q2) The combining form that means egg is ________.
Q3) The combining form that means perineum is ________.
Q4) Multigravida refers to a woman who has had two or more pregnancies.
A)True
B)False
Q5) The suffix that means uterine tube is ________.
Q6) The female external genitalia are collectively referred to as the:
A)vulva
B)vagina
C)clitoris
D)cervix
Q7) Which of the following is not one of the male reproductive glands?
A)bulbourethral
B)prostate
C)seminal vesicle
D)cystic
Q8) A medical term that means pertaining to the embryo is ________.
Q9) The combining form that means vas deferens is ________.
Q10) A medical term that means pertaining to the seminal vesicle is ________. Page 12
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Chapter 11: Endocrine System
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177 Verified Questions
177 Flashcards
Source URL: https://quizplus.com/quiz/19307
Sample Questions
Q1) The combining form that means pineal gland is ________.
Q2) A medical term that means many (excessive)thirst is ________.
Q3) Progesterone helps to maintain the uterine lining for pregnancy.
A)True
B)False
Q4) Which of the following hormones is secreted by the posterior pituitary?
A)oxytocin
B)follicle-stimulating hormone
C)antidiuretic hormone
D)both A and C
Q5) A medical term that means endocrine system disease is ________.
Q6) Which term refers to the condition in which the body tissues contain excessive amounts of fluid?
A)edema
B)exophthalmos
C)gynecomastia
D)hirsutism
Q7) A protein-bound iodine test is used to measure thyroid function.
A)True
B)False
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Chapter 12: Nervous System
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177 Verified Questions
177 Flashcards
Source URL: https://quizplus.com/quiz/19308
Sample Questions
Q1) The suffix that means muscle coordination is ________.
Q2) Which of the following is the location of the nucleus of a neuron?
A)dendrite
B)nerve cell body
C)axon
D)myelin
Q3) Which surgical procedure removes part of a vertebra to relieve pressure on a spinal nerve?
A)cerebrospinal fluid shunt
B)laminectomy
C)carotid endarterectomy
D)nerve block
Q4) Myelography is a diagnostic image produced using ultrasound.
A)True
B)False
Q5) A medical term that means record of brain's electricity is ________.
Q6) Describe the difference between the central nervous system and the peripheral nervous system.
Q7) A medical term that means pertaining to nerves is ________.
Q8) The combining form that means cerebellum is ________.
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Chapter 13: Special Senses: The Eye and Ear
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177 Verified Questions
177 Flashcards
Source URL: https://quizplus.com/quiz/19309
Sample Questions
Q1) A combining form that means water (besides hydr/o)is ________.
Q2) Describe the difference between bone conduction deafness and sensorineural deafness.
Q3) The ear is responsible for two senses: hearing and balance.
A)True
B)False
Q4) Which of the following structures are the sensory receptor cells active in dim light?
A)cones
B)lens
C)rods
D)optic disk
Q5) Glaucoma is the result of a cloudy or opaque lens.
A)True
B)False
Q6) The suffix that means hearing is ________.
Q7) Photophobia is a strong sensitivity to bright light. A)True
B)False
Q8) A medical term that means specialist in measuring vision is ________.
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Chapter 14: Special Topics
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177 Verified Questions
177 Flashcards
Source URL: https://quizplus.com/quiz/19310
Sample Questions
Q1) Antisocial personality disorder includes exaggerated feelings of persecution.
A)True
B)False
Q2) Which of the following terms means the use of heat, cold, or electricity to burn or cut tissues?
A)analgesic
B)cauterization
C)hemostasis
D)resection
Q3) Kleptomania means stealing.
A)True
B)False
Q4) The removal of a small piece of tissue for microscopic examination to assist in a diagnosis is called:
A)a staging laparotomy
B)cytologic testing
C)a biopsy
D)a protocol
Q5) A combining form that means sound is ________.
Q6) A combining form that means drug is ________.
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Chapter 15: Medical Terminology and Anatomy
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100 Verified Questions
100 Flashcards
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Sample Questions
Q1) Which word part frequently gives the location of an organ?
A)suffix
B)word root
C)combining vowel
D)prefix
Q2) Which male reproductive organ contains the seminiferous tubules?
A)vas deferens
B)epididymis
C)seminal vesicles
D)testes
Q3) Which diagnostic procedure provides an X-ray of a joint after injection of a contrast medium into the joint space?
A)arthroscopy
B)myelography
C)dual-energy absorptiometry
D)arthrography
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