Clinical Documentation Exam Review
Course Introduction
Clinical Documentation is a comprehensive course designed to equip students with the knowledge and skills necessary to create accurate, concise, and effective medical records. The course covers the principles and legal requirements of clinical documentation, including patient histories, progress notes, discharge summaries, and electronic health records. Emphasis is placed on the importance of clear communication, confidentiality, and compliance with healthcare regulations and standards. Through case studies and practical exercises, students learn common documentation formats, error prevention strategies, and how high-quality documentation improves patient care, facilitates billing and coding, and supports legal and accreditation processes in medical practice.
Recommended Textbook
Exploring Medical Language 10th Edition by Myrna LaFleur Brooks
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1381 Verified Questions
1381 Flashcards
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Page 2
Chapter 1: Introduction to Medical Language and Evolve
Student Resources
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36 Verified Questions
36 Flashcards
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Sample Questions
Q1) The o in arthr/o/pathy is the A)combining vowel.
B)prefix.
C)word root.
D)suffix.
Answer: A
Q2) A term named for a person or a place,such as Alzheimer disease named for the physician who first described the symptoms as seen in a patient,is
A)an acronym.
B)built from the English language.
C)an eponym.
D)modern language.
Answer: C
Q3) All medical terms have at least one A)prefix.
B)combining vowel.
C)suffix.
D)word root.
Answer: D
Page 3
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Chapter 2: Body Structure, color, and Oncology
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108 Verified Questions
108 Flashcards
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Sample Questions
Q1) The plural form for carcinoma is A)carcinomae.
B)carcinomata.
C)carcinomy.
D)carcinomies.
Answer: B
Q2) The term that means enclosed within a capsule,as with benign or malignant tumors that have not spread beyond the capsule of the organ in which it originated is A)morbidity.
B)exacerbation.
C)remission.
D)encapsulated.
Answer: D
Q3) The term that means disease of the body is A)somatic.
B)somatoplasm.
C)somatogenic.
D)somatopathy.
Answer: D
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Chapter 3: Directional Terms, planes, positions, regions, and Quadrants
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Sample Questions
Q1) Match each item with the correct description below. vertical plane passing through the body from front to back,dividing the body into right and left sides (any plane parallel to the midsagittal plane)
A)sagittal plane
B)transverse plane
C)hypochondriac regions
D)Trendelenburg position
E)Fowler position
F)supine position
Answer: A
Q2) The regions to the right and left of the hypogastric region are the A)iliac.
B)hypochondriac.
C)lumbar.
D)umbilical.
Answer: A
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Page 5
Chapter 4: Integumentary System
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104 Verified Questions
104 Flashcards
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Sample Questions
Q1) The term that means scraping away of the skin by mechanical process or injury is A)laceration.
B)abrasion.
C)contusion.
D)lesion.
Q2) Match each item with the correct description below. dermatology
A)strep
B)TD
C)CMV
D)derm
E)ID
F)CA-MRSA
Q3) Subcutaneous has the same translation as A)epidermal.
B)percutaneous.
C)intradermal.
D)hypodermic.
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6
Chapter 5: Respiratory System and Introduction to Diagnostic
Procedures and Tests
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111 Verified Questions
111 Flashcards
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Sample Questions
Q1) The term that means incomplete expansion in reference to the lung or portion of the lung is
A)bronchitis.
B)bronchiectasis.
C)bronchopneumonia.
D)atelectasis.
Q2) Diaphragmatocele is a hernia of the
A)muscular partition that separates the thoracic cavity from the abdominal cavity.
B)food and air passageway.
C)flap of cartilage covering the larynx.
D)organ with three lobes.
Q3) The term hypoxemia is defined as ________________ in the blood.
A)excessive oxygen
B)deficient oxygen
C)excessive carbon dioxide
D)deficient carbon dioxide
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Chapter 6: Urinary System
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91 Verified Questions
91 Flashcards
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Sample Questions
Q1) A voiding cystourethrography is a radiographic imaging of the A)bladder and the urethra.
B)kidney and ureters.
C)bladder and the ureters.
D)bladder and the kidney.
Q2) Match each item with the correct description below. scanty,few A)urethr/o
B)meat/o
C)olig/o
D)-esis
E)glycos/o
F)azot/o
Q3) Multiple routine tests performed on a urine specimen are called A)KUB.
B)blood urea nitrogen. C)creatinine.
D)urinalysis.
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Chapter 7: Male Reproductive System
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76 Verified Questions
76 Flashcards
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Sample Questions
Q1) The term balanoplasty is defined as
A)the surgical fixation of a testicle.
B)the surgical repair of the glans penis.
C)an excision of the prostate gland.
D)an incision into a testicle.
Q2) Human papillomavirus is also called A)chlamydia.
B)genital warts.
C)human immunodeficiency virus.
D)trichomoniasis.
Q3) The term balanorrhea is defined as
A)a protrusion of the glans penis.
B)discharge from the prostate gland.
C)a stone in the prostate.
D)discharge from the glans penis.
Q4) The combining form that means male is A)sperm/o.
B)balan/o.
C)vas/o.
D)andr/o.
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Chapter 8: Female Reproductive System
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71 Verified Questions
71 Flashcards
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Sample Questions
Q1) The combining form colp/o is defined as A)vagina.
B)uterus.
C)ovary.
D)cul-de-sac.
Q2) Myoma of the uterus is also called A)endometriosis.
B)uterine fibroid.
C)uterine prolapse.
D)adenomyosis.
Q3) TVS is the abbreviation for A)total vaginal hysterectomy.
B)transvaginal hysterectomy.
C)total vaginal hymenectomy.
D)transvaginal sonography.
Q4) The term salpingocele is defined as A)pus in the tube(s)attached to the uterus.
B)scanty menstrual flow.
C)hernia of the uterine tube.
D)painful menstrual flow.
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Chapter 9: Obstetrics and Neonatology
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Sample Questions
Q1) It was an exciting time for the expecting parents when the mother said she "felt the baby move inside her uterus." She was referring to A)colostrum.
B)lactation.
C)quickening.
D)stillborn.
Q2) The premature separation of the placenta from the uterine wall is called A)placenta previa.
B)preeclampsia.
C)stillborn.
D)abruptio placentae.
Q3) During pregnancy the woman had high blood pressure and proteinuria.The obstetrician diagnosed her condition as A)eclampsia.
B)ectopic pregnancy.
C)preeclampsia.
D)abruptio placentae.
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Chapter 10: Cardiovascular,immune,lymphatic Systems and Blood
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99 Verified Questions
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Sample Questions
Q1) The radiographic image of a vein is called a(n) A)angioscopy. B)venogram.
C)arteriogram. D)angiography.
Q2) The combining form isch/o is defined as A)yellowish,fatty plaque.
B)sound.
C)deficiency,blockage. D)clot.
Q3) Excision within the artery (of plaque from the arterial wall)is called A)pericardiostomy. B)phlebectomy.
C)atherectomy. D)endarterectomy.
Q4) The term that means incision into a vein is A)splenectomy. B)phlebotomy.
C)splenorrhaphy. D)valvuloplasty.
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Chapter 11: Digestive System
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Sample Questions
Q1) The surgery performed to treat morbid obesity,which can cause serious illness is A)abdominoperineal resection. B)hemorrhoidectomy. C)vagotomy.
D)bariatric surgery.
Q2) Suturing of the tongue is called A)gingivectomy.
B)cheiloplasty. C)palatoplasty.
D)glossorrhaphy.
Q3) A term that means incision into the abdominal cavity is A)vagotomy.
B)laparotomy. C)pyloromyotomy. D)gastrectomy.
Q4) Feeding a person through a tube is called A)hematemesis. B)reflux. C)lavage. D)gavage.
Page 13
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Chapter 12: Eye
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86 Flashcards
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Sample Questions
Q1) Hemorrhage within the anterior chamber of the eye is A)nystagmus.
B)myopia.
C)hyphema.
D)sty.
Q2) A method to remove cataracts in which an ultrasonic needle breaks up the lens is called
A)scleral buckling.
B)enucleation.
C)trabeculectomy.
D)phacoemulsification.
Q3) The instrument used to measure (the curvature of)the cornea in order to fit a contact lens is the A)optometry.
B)pupillometer.
C)optometer. D)keratometer.
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Chapter 13: Ear
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Sample Questions
Q1) The term otalgia is defined as A)pain in the ear.
B)enlarged auricle.
C)drainage from the middle ear.
D)infection of the eardrum.
Q2) One complication of the patient's upper respiratory infection was inflammation of the bony spaces within the temporal bone of the skull containing the cochlea,the semicircular canals,and the vestibular
A)mastoiditis.
B)myringitis.
C)labyrinthitis.
D)otitis media.
Q3) The combining form that means tympanic membrane (eardrum)is A)myring/o.
B)cochle/o.
C)labyrinth/o.
D)vestibul/o.
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Chapter 14: Musculoskeletal System
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109 Verified Questions
109 Flashcards
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Sample Questions
Q1) The term myasthenia is defined as A)pain in muscle.
B)difficult movement.
C)muscle degeneration.
D)muscle weakness.
Q2) The term chondromalacia is defined as
A)an abnormal condition of stonelike bones.
B)muscle weakness.
C)softening of cartilage.
D)an abnormal condition of a hump.
Q3) The combining form that means bone is A)my/o.
B)arthr/o.
C)synovi/o.
D)oste/o.
Q4) A malignant tumor of the bone is called A)synoviosarcoma.
B)osteofibroma.
C)osteosarcoma.
D)myeloma.
Page 16
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Chapter 15: Nervous System and Behavioral Health
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98 Flashcards
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Sample Questions
Q1) The combining form encephal/o is defined as A)spinal cord.
B)brain.
C)nerve root.
D)cerebellum.
Q2) The psychiatrist has been asked to see a patient who feels a need to continuously wash her hands,now raw from the continuous scrubbing.After consulting with the patient,the psychiatrist concluded that the patient has a disorder characterized by a tendency to perform repetitive actions or rituals called
A)obsessive-compulsive disorder.
B)bipolar disorder.
C)autism.
D)anxiety disorder.
Q3) Which of the following is an eating disorder?
A)Anxiety disorder
B)Bulimia nervosa
C)Phobia
D)Autism
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17
Chapter 16: Endocrine System
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Sample Questions
Q1) The term that means the enlargement of the thyroid gland is A)myxedema.
B)adrenomegaly.
C)goiter.
D)acromegaly.
Q2) The term corticoid means
A)pertaining to the cortex.
B)disease of the adrenal gland.
C)resembling the cortex.
D)excessive development of the adrenal cortex.
Q3) Match each item with the correct description below. run,running
A)endocrin/o
B)dips/o
C)-drome
D)acr/o
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