Clinical Documentation Exam Materials - 5402 Verified Questions

Page 1


Clinical Documentation

Exam Materials

Course Introduction

Clinical Documentation is a comprehensive course designed to equip students with the fundamental principles and practical skills essential for accurate and effective documentation in healthcare settings. The course explores the legal, ethical, and professional standards governing medical records, emphasizing the importance of clear, concise, and timely documentation for patient care, interdisciplinary communication, and regulatory compliance. Students will learn common documentation methods, electronic health record (EHR) systems, confidentiality protocols, error prevention strategies, and the role of clinical documentation in quality assurance and risk management. Through case studies and practical exercises, students will develop the competence needed to ensure that clinical documentation meets current healthcare standards and supports optimal patient outcomes.

Recommended Textbook

The Language of Medicine 11th Edition by Davi Ellen Chabner

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35 Chapters

5402 Verified Questions

5402 Flashcards

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Page 2

Chapter 1: Basic Word Structure

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201 Verified Questions

201 Flashcards

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Sample Questions

Q1) X-rays:

A) radi/o

B) path/o

C) onc/o

Answer: A

Q2) dia-:

A) through; complete

B) self; own

C) behind

Answer: A

Q3) hypo-: __________

Answer: below deficient

Q4) peri-: __________

Answer: surrounding

Q5) Mass of blood: __________oma

Answer: hemat

Q6) X-rays: __________

Answer: radi/o

Page 3

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Chapter 2: Terms Pertaining to the Body as a Whole

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137 Flashcards

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Sample Questions

Q1) A. nucleus

B. neucleus

A or B: ____ meaning: __________.

Answer: A, control center of the cell

Q2) Dorsal: __________

Answer: ventral anterior

Q3) hist/o:

A) nucleus

B) tissue

C) far; distant

Answer: B

Q4) Pertaining to the abdomen:

A) abdominel

B) abdominal

C) abdomineal

Answer: B

Q5) Region of the waist: __________

Answer: lumbar

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Chapter 3: Suffixes

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Sample Questions

Q1) Surgical creation of a permanent opening to the outside of the body:

A) -stomy

B) -tomy

C) -ectomy

D) Section

E) Resection

Answer: A

Q2) Blood is held back from an area:

A) Thrombocyte

B) Anemia

C) Ischemia

D) Hematoma

E) Hemolysis

Answer: C

Q3) -phobia: __________

Answer: fear

Q4) -penia: __________

Answer: deficiency

Q5) Tonsil: __________

Answer: tonsill/o

Page 5

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Chapter 4: Prefixes

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Sample Questions

Q1) Select the term that is spelled correctly:

A) antebody

B) antibody

Q2) Ultrasonography:

A) X-ray recording of sound waves

B) Amniocentesis

C) Sound waves and echoes are used to create an image

D) Radioactive material is injected and sound waves are recorded

E) Abdominal x-ray recording

Q3) hypo-:

A) above, excessive

B) deficient, under

C) surrounding

Q4) seps/o:

A) poison

B) protection

C) infection

Q5) Slow heart rate: __________ cardia

Q6) Pertaining to below the ribs: infra__________

Q7) retro-: __________

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Chapter 5-1: Digestive System Part 1

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Sample Questions

Q1) Pertaining to under the lower jaw

A)choledochojejunostomy

B)enterocolostomy

C)ileostomy

D)labial

E)laparoscopy

F)mesentery

G)palatoplasty

H)parenteral

I)sublingual

J)submandibular

Q2) Salivary gland near the ear:

A) perotid gland

B) parrotid gland

C) parotid gland

Q3) Select the term that is spelled correctly:

A) assites

B) ascites

Q4) Dysentery: __________

Q5) Volvulus: __________

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Chapter 5-2: Digestive System Part 2

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Sample Questions

Q1) Inflammation of the large intestine: __________

Q2) Inflammation of the gums: __________

Q3) Inflammation of the third part of the small intestine: __________itis

Q4) Surgical repair of the roof of the mouth: __________

Q5) Discharge of fat in the feces: __________

Q6) Inflammation of a salivary gland: __________

Q7) Study of the cause (of disease): __________

Q8) Abnormal condition of salivary stones: __________lithiasis

Q9) New opening between the common bile duct and the jejunum: __________

Q10) Presence of fresh, bright red blood in stools: __________

Q11) Inflammation of the pancreas: __________itis

Q12) Inflammation of the third part of the small intestine: __________

Q13) lapar/o and celi/o both mean __________.

Q14) gloss/o and lingu/o both mean __________.

Q16) Pertaining to under the tongue: sub__________ Page 8

Q15) High levels of pigment in the blood (as in jaundice): hyper__________

Q17) New opening between two previously unconnected tubes: enteric

Q18) Gas expelled through the anus: __________

Q19) Inflammation of the mouth: __________

Q20) Inflammation of the appendix: __________

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Chapter 6: Additional Suffixes and Digestive System

Terminology

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Sample Questions

Q1) -ase: __________

Q2) Pertaining to the cheek

A)buccal

B)cecal volvulus

C)celiac disease

D)cheilosis

E)cholelithiasis

F)cholangitis

G)cholecystectomy

H)choledochal

I)colectomy

J)colonoscopy

K)dentalgia

L)duodenal

Q3) dent/i: __________

Q4) Destruction of blood:

A) hemolysis

B) hemmolysis

C) hemolisis

Q5) -ectasia: __________

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Chapter 7-1: Urinary System Part 1

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Sample Questions

Q1) Blood vessel that carries blood away from the kidney

A)arteriole

B)calyx

C)hilum

D)meatus

E)nephron

F)renal tubule

G)trigone

H)renal vein

I)ureter

J)urethra

Q2) dia-: __________

Q3) Group of clinical signs and symptoms caused by excessive protein loss in urine

A)glomerulonephritis

B)interstitial nephritis

C)nephrolithiasis

D)nephrotic syndrome

E)polycystic kidney disease

F)pyelonephritis

Q4) Bacteria in the urine: bacteri__________

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Chapter 7-2: Urinary System Part 2

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Sample Questions

Q1) A. meatis

B. meatus

A or B: _____ meaning: __________

Q2) A. pyleogram

B. pyelogram

A or B: _____ meaning: __________

Q3) Enuresis: __________

Q4) A. abcess

B. abscess

A or B: _____ meaning: __________

Q5) UTI: __________

Q6) Hemodialysis: __________

Q7) Vesicoureteral reflux: __________

Q8) Renal angiography: __________

Q9) A. nitrogenous

B. nitrogenius

A or B: _____ meaning: __________

Q10) Urinary meatal stenosis: __________

Q11) Creatinine: __________

12

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Page 13

Chapter 8-1: Female Reproductive System Part 1

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240 Verified Questions

240 Flashcards

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Sample Questions

Q1) False pregnancy: pseudo__________

Q2) pre-: __________

Q3) Surgical puncture to remove fluid from the amniotic cavity

A)amniocentesis

B)amniotic fluid

C)endocervicitis

D)chorionic

E)colposcopy

F)culdocentesis

G)episiotomy

H)galactorrhea

I)gynecomastia

J)lactation

Q4) Cone-shaped section of the cervix is removed: __________

Q5) Removal of an ovary: __________ectomy

Q6) Muscular tube leading from the uterus:

A) vagina

B) vajina

C) vigina

Q7) peri-: __________

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Chapter 8-2: Female Reproductive System Part 2

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Sample Questions

Q1) A. carsinoma en situ

B. carcinoma in situ

A or B: _____ meaning: __________

Q2) Gamete: __________

Q3) A. amenorhea

B. amenorrhea

A or B: _____ meaning: __________

Q4) A. cervisitis

B. cervicitis

A or B: _____ meaning: __________

Q5) A. esterogen

B. estrogen

A or B: _____ meaning: __________

Q6) episi/o and vulv/o mean: __________

Q7) A. areola

B. aereola

A or B: _____ meaning: __________

Q8) -cyesis and gravid/o mean: __________

Page 15

Q9) Gravida: __________

Q10) Primipara: __________

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Page 16

Chapter 9: Male Reproductive System

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Sample Questions

Q1) Prostatectomy: __________

Q2) Circumcision

A)carcinoma of the prostate gland

B)cryptorchism

C)sterilization (hormones remain)

D)benign prostatic hyperplasia

E)reversal of sterilization

F)removal of swollen, twisted veins near the testes

G)abnormal fluid collection in scrotum

H)seminoma

I)phimosis

Q3) Swollen, twisted veins near the testes:

A) Varicocele

B) Hydrocele

C) Hypospadias

D) Herpes genitalis

E) Testicular torsion

Q4) Hernia of fluid in the scrotal sac: hydro__________

Q5) Undescended testicles: __________

Q6) Testicular teratoma: __________

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Chapter 10-1: Nervous System Part 1

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238 Flashcards

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Sample Questions

Q1) Canals in the interior of the brain containing cerebrospinal fluid

A)brainstem

B)blood-brain barrier

C)gyrus

D)receptor

E)ventricles of the brain

F)cauda equina

G)ganglion

H)plexus

I)sulcus

J)stimulus

Q2) Contains cerebrospinal fluid

A)gyri

B)neurotransmitter

C)parenchymal cell

D)pia mater

E)sensory nerve

F)subarachnoid space

Q3) sub-: __________

Q4) kines/o: __________

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Chapter 10-2: Nervous System Part 2

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32 Verified Questions

32 Flashcards

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Sample Questions

Q1) A. motor nerve

B. moter nerve

A or B: _____ meaning: __________

Q2) Angiography: __________

Q3) Meningomyelocele: __________

Q4) A. neurasthenia

B. neurastenea

A or B: _____ meaning: __________

Q5) Cerebral embolus: __________

Q6) A. pareasis

B. paresis

A or B: _____ meaning: __________

Q7) A. acetylcholene

B. acetylcholine

A or B: _____ meaning: __________

Q8) Narcolepsy: __________

Q9) Paresthesias: __________

Q10) Shingles: __________

Q11) Hypothalamus: __________

19

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Page 20

Chapter 11-1: Cardiovascular System Part 1

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232 Verified Questions

232 Flashcards

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Sample Questions

Q1) Upper chamber of the heart

A)aorta

B)arteriole

C)atrium

D)capillary

E)mitral valve

F)pulmonary artery

G)pulmonary vein

H)superior vena cava

I)tricuspid valve

J)ventricle

Q2) LVAD: __________

Q3) Vasoconstriction: __________

Q4) Angina is:

A) Chest pain relieved with nitroglycerin

B) An extra heart sound

C) An abnormal heart rhythm

D) Caused by rheumatic fever

E) Associated with Raynaud phenomenon

Q5) Heart block: __________

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Chapter 11-2: Cardiovascular System Part 2

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60 Verified Questions

60 Flashcards

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Sample Questions

Q1) hypo-: __________

Q2) pulmon/o: __________

Q3) cyan/o: __________

Q4) inter-: __________

Q5) The pacemaker of the heart is the __________.

Q6) The sac-like membrane surrounding the heart is the __________.

Q7) -sclerosis: __________

Q8) -plasty: __________

Q9) Widening of a blood vessel: vaso__________

Q10) peri-: __________

Q11) The relaxation phase of the heartbeat is called __________.

Q12) coron/o: __________

Q13) aort/o: __________

Q14) myx/o: __________

Q15) -graphy: __________

Q16) Condition of rapid heartbeat: __________cardia Page 22

Q17) vas/o: __________

Q18) atri/o: __________

Q19) -tomy: __________

Q20) -stenosis: __________

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Chapter 12-1: Respiratory System Part 1

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240 Verified Questions

240 Flashcards

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Sample Questions

Q1) Lung disease marked by distention or swelling of the alveoli: em__________

Q2) Pertaining to a sudden occurrence

A)anthracosis

B)asbestosis

C)bacilli

D)chronic obstructive pulmonary disease (COPD)

E)cor pulmonale

F)exudate

G)hydrothorax

H)infiltrate

I)palliative

J)paroxysmal

K)pneumothorax

L)pulmonary infarction

M)purulent

N)silicosis

Q3) Diaphragm: __________

Q4) Tonsils: __________

Q5) Voice box: __________

Q6) Blue: __________

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Chapter 12-2: Respiratory System Part 2

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Sample Questions

Q1) Bronchiectasis: __________

Q2) NSCLC: __________

Q3) Pulmonary infarction: __________

Q4) COPD: __________

Q5) A. plural

B. pleural

A or B: _____ meaning: __________

Q6) A. diaphrame

B. diaphragm

A or B: _____ meaning: __________

Q7) PFTs: __________

Q8) URI: __________

Q9) Bronchoscopy: __________

Q10) Tachypnea: __________

Q11) Dyspnea: __________

Q12) Pleural effusion: __________

Q13) RSV: __________ Page 25

B. alveroli

A or B: _____ meaning: __________

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Chapter 13-1: Blood System Part 1

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233 Verified Questions

233 Flashcards

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Sample Questions

Q1) Method of separating serum proteins by electrical charge

A)albumin

B)antibody

C)antigen

D)basophil

E)bilirubin

F)coagulation

G)differentiation

H)electrophoresis

I)eosinophil

J)erythrocyte

K)erythropoietin

L)fibrin

Q2) Select the term that is spelled correctly:

A) thallassemia

B) thalassemia

Q3) -blast: __________

Q4) Select the term that is spelled correctly:

A) myeloma

B) myleoma

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Chapter 13-2: Blood System Part 2

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31 Flashcards

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Sample Questions

Q1) Autoimmune thrombocytopenic purpura: __________

Q2) Eosinophil: __________

Q3) Hemophilia: __________

Q4) What is serum?

Q5) A. electropheresis

B. electrophoresis

A or B: _____ meaning: __________

Q6) Differentiation: __________

Q7) Myelopoiesis: __________

Q8) What is a neutrophil?

Q9) Purpura: __________

Q10) Sickle cell anemia: __________

Q11) CLL: __________

Q12) Erythropoietin: __________

Q13) What is a hematopoietic stem cell?

Q14) A. erythropoeisis

B. erythropoiesis Page 28

or B: _____ meaning: __________

Q15) Thrombolytic: __________

Q16) Anticoagulant: __________

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Chapter 14-1: Lymphatic and Immune Systems Part 1

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Sample Questions

Q1) Bacterial disease manifesting with fever, malaise, night sweats, diarrhea, lung, and blood infections (MAI)

A)Candidiasis

B)Cryptococcus

C)Cryptosporidiosis

D)Cytomegalovirus infection

E)Herpes simplex

F)Histoplasmosis

G)Mycobacterium avium-intracellulare infection

H)Pneumocystis jiroveci (formerly carinii) pneumonia

I)Toxoplasmosis

J)Tuberculosis

Q2) Inguinal nodes: __________

Q3) Malignant tumor of lymph nodes:

A) Sarcoidosis

B) Lymphedema

C) Hodgkin lymphoma

D) Hypersplenism

E) Lymphocytopenia

Q4) Stationary lymph tissue along the path of lymph vessels: __________

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Chapter 14-2: Lymphatic and Immune Systems Part 2

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Sample Questions

Q1) HIV: __________

Q2) RTI: __________

Q3) Toxo: __________

Q4) Histo: __________

Q5) Inguinal nodes: __________

Q6) HD: __________

Q7) Lymphedema: __________

Q8) HIV: __________

Q9) NK cells: __________

Q10) A. alergy

B. allergy

A or B: _____ meaning: __________

Q11) A. splenectomy

B. spleenectomy

A or B: _____ meaning: __________

Q12) Hypersplenism: __________

Q13) HAART: __________

31

Q15) HSV: __________

Q16) Anaphylaxis: __________

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Chapter 15-1: Musculoskeletal System Part 1

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Sample Questions

Q1) Inflammation of bone and bone marrow:

A) Osteitis fibrosa cystica

B) Multiple myeloma

C) Osteomyelitis

D) Osteoporosis

E) Osteochondroma

Q2) Soft bone tissue found in cancellous bone; contains hematopoietic stem cells and blood cells

A)phosphorus

B)pubic symphysis

C)red bone marrow

D)sella turcica

E)sinus

F)styloid process

G)tubercle

H)temporomandibular joint

I)trabeculae

J)trochanter

Q3) Rounded depression or socket in the pelvis; forms the hip joint

Q4) Skull bones: ethmoid, frontal, occipital, parietal, sphenoid, and temporal

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Chapter 15-2: Musculoskeletal System Part 2

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Sample Questions

Q1) Fascia: __________

Q2) -algia: __________

Q3) ab-: __________

Q4) The bones of a fetus are mainly composed of __________ tissue.

Q5) Flesh: __________

Q6) -malacia: __________

Q7) Fluid found within the joint is called _____ fluid.

Q8) Subluxation: __________

Q9) supra-: __________

Q10) Osteodystrophy: __________

Q11) metatars/o: ___________________

Q12) myos/o: ___________________

Q13) exo-: __________

Q14) Tumor (benign) of cartilage: __________oma

Q15) ad-: __________

Q16) Connective tissue that binds bones to other bones is a/an __________. Page 34

Q17) Inflammation of bone and bone marrow: __________itis

Q18) Arthrodesis: __________

Q19) peri-: __________

Q20) DEXA: __________

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Chapter 16-1: Skin Part 1

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Sample Questions

Q1) Bed sore; break in continuity of skin:

A) Leukoplakia

B) Psoriasis

C) Tinea

D) Decubitus ulcer

E) Scleroderma

Q2) Chronic recurrent dermatosis with silvery gray scales covering red patches in skin:

A) Leukoplakia

B) Psoriasis

C) Tinea

D) Decubitus ulcer

E) Scleroderma

Q3) Select the term that is spelled correctly:

A) callis

B) callus

Q4) myc/o: __________

Q5) dermat/o: __________

Q6) Under the nail: sub__________

Q7) White patches on mucous membrane of tongue or cheek: leuko__________

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Chapter 16-2: Skin Part 2

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Sample Questions

Q1) Pilonidal cyst: __________

Q2) A. dermatophytosis B. dermatophitosis

A or B: _____ meaning: __________

Q3) Erythema: __________

Q4) Albinism: __________

Q5) Sebaceous gland: __________

Q6) A. verruca B. veruca

A or B: _____ meaning: __________

Q7) A. keratosis B. carrotosis

A or B: _____ meaning: __________

Q8) A. callis B. callus

A or B: _____ meaning: __________

Q9) A. tinnea B. tinea

A or B: _____ meaning: __________

Q10) Vitiligo: __________

Q11) A. wheel B. wheal

A or B: _____ meaning: __________

Q12) A. subungwnal B. subungual

A or B: _____ meaning: __________

37

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Chapter 17-1: Sense Organs: The Eye and the Ear Part 1

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Sample Questions

Q1) Structure on either side of the lens that connects the choroid and iris; it alters the shape of the lens

A)accommodation

B)anterior chamber

C)aqueous humor

D)biconvex

E)choroid

F)vitreous humor

G)ciliary body

H)cone

I)conjunctiva

J)cornea

K)fovea centralis

L)rod

Q2) Select the term that is spelled correctly:

A) cilliary body

B) ciliary body

Q3) Select the term that is spelled correctly:

A) acqueous humer

B) aqueous humor

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Chapter 17-2: Sense Organs: The Eye and the Ear Part 2

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Sample Questions

Q1) Tympanic membrane: __________

Q2) tympan/o: __________

Q3) VF: __________

Q4) corne/o: __________

Q5) The normal adjustment of the lens to bring an object into focus is called __________.

Q6) A yellowish region on the retina lateral to the optic disc is the _______.

Q7) A. conjuntivia B. conjunctiva

A or B: _____ meaning: __________

Q8) -tropia: __________

Q9) conjunctiv/o: __________

Q10) Paralysis of the eye: __________o__________

Q11) Pertaining to the eustachian tube and the throat: __________eal

Q12) AS: __________

Q13) nyct/o: __________

Q14) Palpebral: __________

40

Q15) Instrument to measure hearing: __________meter

Q17) ocul/o: __________

Q18) Vertigo: __________

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Chapter 18-1: Endocrine System Part 1

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Sample Questions

Q1) Select the term that is spelled correctly:

A) corticosteroid

B) cortikosteroid

Q2) Stimulates water reabsorption by kidney tubules; decreases urine

A)adrenocorticotropic hormone (ACTH)

B)antidiuretic hormone (ADH)

C)aldosterone

D)cortisol

E)estradiol

F)insulin

G)epinephrine

H)testosterone

I)thyroxine

J)parathyroid hormone

Q3) Removal of the pancreas: __________ectomy

Q4) Select the term that is spelled correctly:

A) goiter

B) goyter

Q5) andr/o: __________

Q6) gluc/o: __________

42

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Chapter 18-2: Endocrine System Part 2

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Sample Questions

Q1) A. courtisol

B. cortisol

A or B: _____ meaning: __________

Q2) A. uthyroid

B. euthyroid

A or B: _____ meaning: __________

Q3) A. hypocalemia

B. hypokalemia

A or B: _____ meaning: __________

Q4) Homeostasis: __________

Q5) Glycosuria: __________

Q6) A. goiter

B. goyter

A or B: _____ meaning: __________

Q7) Myxedema-hyper or hypo: _____ endocrine gland involved: __________

Q8) ACTH: __________

Q9) ADH: __________

Q10) Exophthalmos: __________

Q11) Polydipsia: __________

43

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Page 44

Chapter 19-1: Cancer Medicine (Oncology) Part 1

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Sample Questions

Q1) follicul/o: __________

Q2) Cells are scraped off tissue and microscopically examined

A)b-hCG test

B)bone marrow biopsy

C)CA-125

D)CEA test

E)estrogen receptor assay

F)exfoliative cytology

G)laparoscopy

H)core needle biopsy

I)PSA test

J)fine needle aspiration

Q3) apo-: __________

Q4) Patterns resembling small, microscopic sacs: alveol__________

Q5) brachy-: __________

Q6) Additional treatment:

A) adjuvant chemotherapy

B) adjivent chemotherapy

C) adjuvent chemotherapy

Q7) polyp/o: __________

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Chapter 19-2: Cancer Medicine (Oncology) Part 2

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Sample Questions

Q1) Pedunculated: __________

Q2) Cauterization: __________

Q3) A. retinoblastoma

B. retinoblasoma

A or B: _____ meaning: __________

Q4) differentiation: __________

Q5) A. hyperplasia

B. hyperplayzea

A or B: _____ meaning: __________

Q6) protocol: __________

Q7) Gy: __________

Q8) A. displastic

B. dysplastic

A or B: _____ meaning: __________

Q9) EPO: __________

Q10) osteosarcoma: __________

Q11) PSCT: __________

Q12) Laparoscopy: __________

Q14) neoplasm: __________

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Chapter 20: Radiology and Nuclear Medicine

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Sample Questions

Q1) son/o: __________

Q2) Radioactive drug (radionuclide plus chemical) is administered for diagnostic and therapeutic purposes

A)radiopaque

B)radiopharmaceutical

C)scan

D)half-life

E)transducer

F)tagging

G)ultrasound

H)uptake

I)ventilation/perfusion studies

J)single-photon emission computed tomography

Q3) Radioisotope: __________

Q4) A. radiopharmaceutical

B. radiopharmaseutical

A or B: _____ meaning: __________

Q5) -graphy: __________

Q6) Posteroanterior: __________

Q7) is/o: __________

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Chapter 21: Pharmacology

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Sample Questions

Q1) A. antipyretic

B. antepyretic

A or B: _____ meaning: __________

Q2) Drug that blocks the entrance of calcium into heart muscle and lining of blood vessels; antihypertensive, antiarrhythmic, and antianginal drug

A)antibiotic

B)beta-blocker

C)bisphosphonate

D)caffeine

E)calcium channel blocker

F)cathartic

G)diuretic

H)emetic

I)glucocorticoid

J)hypnotic

Q3) hypn/o: __________

Q4) Hypersensitivity reaction:

A) anaphilaxis

B) anaphylaxis

C) antiphylaxis

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Chapter 22: Psychiatry

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Sample Questions

Q1) Patients express feelings by acting out roles with other patients: __________

Q2) Confusion in thinking associated with faulty perceptions and irrational behavior

A)anxiety disorders

B)delirium

C)dementia

D)dissociative disorders

E)eating disorder

F)personality disorder

G)sexual disorders

H)Somatic symptom disorders

I)substance-related and addictive disorders

Q3) A. schizophrenia

B. shizophrenia

A or B: _____ meaning: __________

Q4) A. bulemia nervosa

B. bulimia nervosa

A or B: _____ meaning: __________

Q5) Minor tranquilizers and sedatives used to reduce tension: __________ agents

Q6) -phoria: __________

Q7) Agoraphobia: __________

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