Clinical Documentation Exam Bank
Course Introduction
Clinical Documentation covers the principles, standards, and best practices related to the accurate and comprehensive recording of patient information in healthcare settings. Students will learn the critical role of documentation in clinical care, communication among healthcare providers, legal considerations, reimbursement processes, and quality assurance. The course also explores electronic health records (EHR), confidentiality and security of patient data, and methods for improving documentation efficiency and reducing errors. Emphasis is placed on real-world case studies and hands-on exercises to develop proficiency in documenting clinical encounters, interventions, assessments, and follow-up care.
Recommended Textbook
Essentials of Medical Language 3rd Edition by
David Allan
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16 Chapters
2522 Verified Questions
2522 Flashcards
Source URL: https://quizplus.com/study-set/3137
Page 2
Chapter 1: The Anatomy of Word Construction: the Essential Elements of
the Language of Medicine
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107 Verified Questions
107 Flashcards
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Sample Questions
Q1) A specialist who would treat a patient with pneumonia is a(n): A)bronchitis.
B)respiration.
C)pulmonologist.
D)urology.
E)neurologist.
Answer: C
Q2) When deconstructing a medical term, the first element you should identify is the: A)root. B)prefix.
C)combining form.
D)suffix.
E)combining vowel.
Answer: D
Q3) Write the word that the pronunciation key is describing, HIGH-po-TEN-siv.
Answer: hypotensive
Q4) The tube that carries urine from the kidney to the bladder. Answer: ureter
Page 3
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Chapter 2: The Body As a Whole: The Essentials of the Language of Anatomy
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105 Verified Questions
105 Flashcards
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Sample Questions
Q1) Write the medical term that means systematic treatment of a disease, dysfunction, or disorder.
Answer: therapy
Q2) The correct spelling of the term for a crescent-shaped cartilaginous structure in the knee is: A)miniskus. B)menescus. C)menisgus. D)miniscus. E)meniscus.
Answer: E
Q3) The medical term that means tissue that surrounds the bone: A)skeleton. B)ligament. C)tendon. D)capsular. E)periosteum. Answer: E
Q4) Write the medical term that means study of the structure of the human body. Answer: anatomy
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Chapter 3: The Integumentary System: The Essentials of the
Language of Dermatology
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108 Verified Questions
108 Flashcards
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Sample Questions
Q1) The medical term that means fibrotic seam that forms when a wound heals
Answer: scar
Q2) The term that means the process of building a compound from different elements:
A)catabolism.
B)excretion.
C)biopsy.
D)cutaneous.
E)synthesis.
Answer: E
Q3) The term that means removing tissue from a living person for laboratory examination is: A)biopsy. B)excision. C)avulsion.
D)dermabrasion.
E)dermatectomy.
Answer: A
Page 5
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Chapter 4: The Skeletal System: The Essentials of the
Language of Orthopedics
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147 Verified Questions
147 Flashcards
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Sample Questions
Q1) In the term avascular necrosis, what does the word necrosis refer to?
A)Cut off
B)Non-weight-bearing
C)Without a blood supply
D)Death
E)Wasting
Q2) Women at risk for developing osteoporosis should have a bone mineral density (BMD) screening using which of the following procedures?
A)MRI
B)CT
C)FDA
D)PET
E)DEXA
Q3) In the word detoxification, what is the prefix and what does the prefix mean?
A)The prefix is de-, and it means pertaining to.
B)The prefix is -toxi-, and it means poison.
C)The prefix is de-, and it means from, out of.
D)The prefix is -fication, and it means remove.
E)The prefix is detox-, and it means substance.
Q4) Correctly spell the term that means treatment using chemical agents.
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Chapter 5: Muscles and Tendons: The Essentials of the
Languages of Orthopedics and Rehabilitation
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114 Verified Questions
114 Flashcards
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Sample Questions
Q1) The member of the multidisciplinary team that works with the specialist in charge of helping patients with activities of daily living is a(n):
A)PTA
B)PT
C)OTA
D)DO
E)ROM
Q2) Mr.Soklov suffered a stroke resulting in weakness over the left side of his body.Which health care professional will be consulted to improve Mr.Soklov's strength?
A)Orthotist
B)Social worker
C)Physical therapist
D)Occupational therapist
E)Orthopedic technician
Q3) The term that means tissue consisting of contractile cells is:
Q4) The medical term that means inflammation of a muscle tissue.
Q5) The medical term that is a substance that causes failure of the immune system:
Page 7
Q6) The medical term that means having the function of walking.
Q7) The medical term that means wasting away or loss of volume of muscle tissue:
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Chapter 6: Cardiovascular and Circulatory Systems: the Essentials of the Language of Cardiology
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205 Verified Questions
205 Flashcards
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Sample Questions
Q1) The area between the lungs that contains the heart, aorta, venae cavae, esophagus, and trachea is known as the:
A)mediastinum.
B)sternum.
C)septum.
D)myocardium.
E)intercostal space.
Q2) Which type of medication would be used to treat symptomatic bradycardia?
A)Diuretic
B)Anticoagulant
C)Vasodilator
D)Chronotropic
Q3) A procedure which uses a catheter with an electrode in its tip to destroy the cells from which abnormal cardiac rhythms are originating is called a(n):
A)radiofrequency ablation.
B)defibrillation.
C)cardioversion.
D)stent placement.
E)heart transplant.
8
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The Essentials of the Languages of Hematology and Immunology
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180 Verified Questions
180 Flashcards
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Sample Questions
Q1) What is the medical definition of the term heparin?
A)A protein molecule that is produced in the spleen.
B)A small cell without any granules.
C)A thrombolytic that is secreted by leukocytes.
D)An anticoagulant that is secreted by basophils.
E)A probiotic that is ingested to prevent blood clots.
Q2) Which of the following terms has a word element meaning clot?
A)Erythrocytes
B)Pernicious
C)Thrombocytopenia
D)Aplastic
E)Mononucleosis
Q3) The blood cell that forms collagen fibers is a:
A)fibrin.
B)monocyte.
C)myeloid.
D)fibroblast.
Q4) A medical specialist in disorders of the blood is called a _________.
Q5) A clot attached to a diseased blood vessel or heart lining is called a _________. Page 9
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Page 10
Chapter 8: Respiratory System: The Essentials of the
Language of Pulmonology
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169 Verified Questions
169 Flashcards
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Sample Questions
Q1) The alveolus is:
A)one of the lobes of the lung.
B)one of the breath sounds.
C)the terminal element of the respiratory tract.
D)the site at which oxygen is exhaled.
E)located above the sternal notch.
Q2) The respiratory therapist counts a patient's respiratory rate at 6 breaths per minute.What condition does this indicate?
A)Tachypnea
B)Eupnea
C)Bradypnea
D)Apnea
Q3) Which of the following terms is from the Latin origin meaning passage?
A)Concha
B)Fossa
C)Fistula
D)Meatus
E)Fissure
Q4) The diagnostic method of listening to body sounds with a stethoscope is called
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Chapter 9: The Digestive System: The Essentials of the
Language of Gastroenterology
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167 Verified Questions
167 Flashcards
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Sample Questions
Q1) What is secreted by the islet cells of the pancreas?
A)Vitamins
B)Glucose
C)Insulin
D)Glucagon
E)Insulin and glucagon
Q2) The term for a small projection is ______________, and its plural is ______________.
A)palate; palates
B)papila; papillas
C)papilla; papillae
D)plaque; plaques
E)pulp; pulpes
Q3) An infection of the mouth by Candida albicans is correctly documented as:
A)aphthous.
B)halitosis.
C)metastasis.
D)hematemesis.
E)thrush.
Q4) The _________ closes so that food cannot enter the larynx and trachea.
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Neurology and Psychiatry
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191 Verified Questions
191 Flashcards
Source URL: https://quizplus.com/quiz/62134
Sample Questions
Q1) Fear of crowded places is:
A)arachnophobia.
B)claustrophobia. C)acrophobia.
D)agoraphobia.
E)pyromania.
Q2) Another term used for contusion is:
A)compression.
B)concussion. C)bruise.
D)athetosis.
E)ataxia.
Q3) A collection of blood located outside the dura mater is called a(n):
A)intracranial hemorrhage.
B)epidural hematoma.
C)cerebral concussion.
D)intercranial hemorrhage.
E)subdural hematoma.
Q4) A medical specialist in disorders of the nervous system is a _________.
Q5) A wasting or diminished volume of an organ or tissue is called _________.
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Chapter 11: Special Senses of the Eye and Ear: The Essentials of
the Languages of Ophthalmology and Otology
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194 Verified Questions
194 Flashcards
Source URL: https://quizplus.com/quiz/62133
Sample Questions
Q1) The study of hearing disorders is called _________.
Q2) Where is the area of sharpest vision in the eye?
A)Optic nerve
B)Macula lutea
C)Fovea centralis
D)Uvea
E)Optic disc
Q3) If both ears are affected by otosclerosis, the condition is:
A)unilateral.
B)chronic.
C)bilateral.
D)quadrilateral.
E)acute.
Q4) The instruction every four hours is abbreviated:
A)q.i.d.
B)b.i.d.
C)q.4h.
D)t.i.d.
E)p.r.n.
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Q5) The name of the bony socket that holds the eyeball is called the _________.
Chapter 12: The Endocrine System: The Essentials of the
Language of Endocrinology
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165 Verified Questions
165 Flashcards
Source URL: https://quizplus.com/quiz/62132
Sample Questions
Q1) A patient arrives to the clinic complaining of unexplained weight loss, diarrhea, and profuse sweating.On exam, the nurse practitioner notices the presence of a goiter.Based on the signs and symptoms, the nurse practitioner suspects:
A)diabetes mellitus.
B)addison disease.
C)cushing disease.
D)hypothyroidism.
E)hyperthyroidism.
Q2) Which of the following is NOT a function of a thyroid hormone?
A)Increase in the amount of oxygen that cells use
B)Control of metabolic rate
C)Stimulation of tissues to produce proteins
D)Secretion of leptin
E)Moving calcium from blood to bone
Q3) The medical term that means salt solution:
A)exocrine.
B)ketone.
C)acetone.
D)insulin.
E)saline.
15
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Chapter 13: The Urinary System: The Essentials of the Language of Urology
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187 Verified Questions
187 Flashcards
Source URL: https://quizplus.com/quiz/62131
Sample Questions
Q1) An enlarged prostate gland can cause:
A)urinary incontinence.
B)bladder cancer.
C)chronic urinary retention.
D)pyelonephritis.
E)chronic glomerulonephritis.
Q2) Dr.Baker has diagnosed Mr.Johnson with incontinence.This means Mr.Johnson:
A)has pain when he urinates.
B)has a very slow stream of urine.
C)is unable to prevent discharge of urine or feces.
D)has blood in his urine.
E)voids scant amounts of urine.
Q3) An infection of the renal pelvis is called:
A)cystitis.
B)urethritis.
C)pyelitis.
D)ureteritis.
E)pyonephrosis.
Q4) An agent that increases urine output is called a _________.
Q5) Outer layer of an organ is _______________________.
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Chapter 14: The Male Reproductive System: The Essentials
of the Language of the Male Reproductive System
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181 Verified Questions
181 Flashcards
Source URL: https://quizplus.com/quiz/62130
Sample Questions
Q1) In which of the following conditions is there a deficiency of testosterone?
A)Male infertility
B)Hypogonadism
C)Prostatic cancer
D)Prostatic hyperplasia
E)Cryptorchism
Q2) In the term hydrocele, the root means :
A)testis.
B)water.
C)sperm.
D)ovum.
E)acorn.
Q3) The name of the medical specialty that focuses on diseases of the genitourinary tract is _________.
Q4) Which of these is not a component of the male reproductive system?
A)Gonads
B)Epididymis
C)Ureters
D)Prostate
E)Penis
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Chapter 15: The Female Reproductive System: The
Essentials of the Language of Gynecology and Obstetrics
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192 Verified Questions
192 Flashcards
Source URL: https://quizplus.com/quiz/62129
Sample Questions
Q1) A baby born after 42 weeks gestation is classified as _________.
Q2) Paget disease is often associated with:
A)cancer.
B)rheumatoid arthritis.
C)multiple sclerosis.
D)diabetes mellitus.
E)heart disease.
Q3) In Latin trimester means :
A)six weeks' duration.
B)four months' duration.
C)three months' duration.
D)two months' duration.
E)one month's duration.
Q4) An incision made into the vulva to enlarge the opening and prevent tearing is called a(n):
A)episiotomy.
B)vulvotomy.
C)vulvectomy.
D)perineotomy.
E)episiectomy.
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Chapter 16: Word Parts and Abbreviations
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110 Verified Questions
110 Flashcards
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Sample Questions
Q1) Which of the following occurs more commonly in female infants and after a breech delivery?
A)Cleft palate
B)Developmental dysplasia of the hip
C)Spina bifida cystica
D)Meconium aspiration syndrome
E)Cyanosis
Q2) Which of the following words means the first bowel movement of the newborn?
A)Meconium
B)Enuresis
C)Hydrocephalus
D)Fistula
E)Myelocele
Q3) Which of the following words means a set of four congenital heart defects occurring together?
A)Trigeminal
B)Tetrahedron
C)Tetralogy
D)Polydactyly
E)Polyhydramnios
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