Healthcare Documentation Exam Questions
Course Introduction
Healthcare Documentation introduces students to the principles and practices of accurately recording patient information within various healthcare settings. The course covers medical terminologies, healthcare systems, and documentation standards required for electronic health records (EHRs) and traditional paper-based charts. Emphasis is placed on legal and ethical considerations, privacy regulations such as HIPAA, and effective communication among healthcare providers. Students learn to produce clear, concise, and comprehensive medical reports, discharge summaries, progress notes, and other essential documents to support quality patient care and facilitate healthcare operations.
Recommended Textbook
Quick and Easy Medical Terminology 8th Edition by Peggy C. Leonard
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Page 2
Chapter 2: Suffixes and Combining Forms Made Easy
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Sample Questions
Q1) Which of the following terms refers to an enzyme that breaks down protein?
A) protease
B) proteinous
C) proteogenesis
D) proteolysis
Answer: A
Q2) A medical specialty that is particularly concerned with malignant tumors and their treatment is called:
A) endocrinology
B) oncology
C) ophthalmologist
D) pathology
Answer: B
Q3) A term that means pertaining to the eye is:
A) adenic
B) ophthalmic
C) otic
D) vascular
Answer: B
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Page 3
Chapter 3: Essential Prefixes and More
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Sample Questions
Q1) You are working with a patient in the intensive care unit. Her heart rate is 40 beats per minute. This is documented as:
A) bradycardia
B) bradyphasia
C) tachycardia
D) tachyphasia
Answer: A
Q2) Which of the following terms contains a word part that means yellow?
A) chloropia
B) cyanotic
C) melancholy
D) xanthosis
Answer: D
Q3) Carcinoma means the same as:
A) cancer
B) fungus
C) stupor
D) syndrome
Answer: A
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Page 4
Chapter 4: Diagnostic Procedures and Therapeutic Interventions
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Sample Questions
Q1) Feeling the texture, size, consistency, and location of certain body parts with the hands is:
A) auscultation
B) inspection
C) palpation
D) percussion
Q2) A general term for a procedure that requires entry of a body cavity or interruption of normal body function is:
A) acute
B) benign
C) inspection
D) invasive
Q3) A pain-relieving pharmaceutical is referred to as a(n) _____.
Q4) The term for substances that produce insensibility or stupor is :
A) anesthetics
B) antibiotics
C) narcotics
D) over-the-counter (OTC) drugs
Page 5
Q5) Listening for sounds within the body with a stethoscope is called _____.
Q6) Drugs that destroy or inhibit the growth of microbes are _____.
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Chapter 5: The Body As a Whole
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Sample Questions
Q1) Sudoriferous glands are the same as _____ glands.
A) adrenal
B) endocrine
C) sex
D) sweat
Q2) The four main types of tissue are:
A) caudal, cephalic, lateral, and medial
B) cephalic, dermal, muscular, and nervous
C) cephalic, lateral, medial, and posterior
D) connective, epithelial, muscular, and nervous
Q3) Laparoscopy means :
A) endoscopic examination of the abdomen
B) incision of the abdominal wall
C) surgical fixation of the abdominal wall
D) suture of the abdominal wall
Q4) A term that means situated in the front and toward the midline of the body is:
A) anteromedian
B) dorsoventral
C) mediolateral
D) posteromedian
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Chapter 6: Musculoskeletal System
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Sample Questions
Q1) Osteoid means _____ bone.
A) growth of
B) inflammation of
C) resembling
D) softening of
Q2) A co-worker complains of numbness and tingling in the hands when typing. You suspect carpal tunnel syndrome which affects the _____ nerve.
A) brachial
B) median
C) radial
D) ulnar
Q3) Which is the procedure done to collect a sample cerebrospinal fluid?
A) craniectomy
B) diskectomy
C) laminectomy
D) lumbar puncture
Q4) Pertaining to the lower back is referred to as _____.
Q5) ____ means pertaining to the collarbone.
Q6) _____ is defined as the production of blood cells.
Q7) _____ means pertaining to the brain and spine.
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Chapter 7: Circulatory System
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Sample Questions
Q1) Inflammation of a lymph node is called _____.
Q2) Electric shock used to terminate cardiac arrhythmias is called:
A) cardiopulmonary bypass
B) cardioversion
C) electrocardiography
D) positron emission
Q3) The term for an electrical device that can keep the heart rhythm within a desirable range is:
A) cardiac pacemaker
B) cardiac resuscitation
C) cardiopulmonary bypass
D) defibrillator
Q4) Increased blood pressure is referred to as _____.
Q5) Inflammation of the lining of the heart is:
A) endocarditis
B) myocarditis
C) pericarditis
D) polyarteritis
Q6) Removal of the tonsils is a(n) _____.
Q7) A slow pulse rate is referred to as _____.
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Chapter 8: Respiratory System
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Sample Questions
Q1) A 23-year-old opera singer complains of hoarseness. The term that best describes this is:
A) aphasia
B) dysphagia
C) dysphasia
D) dysphonia
Q2) One of your patients is a 1-year-old child with recurrent ear infections of the eustachian tubes, which are also referred to as which type of tube?
A) nasopharyngeal
B) nasoplasty
C) otopharyngeal
D) otoplasty
Q3) The term for an agent that is used to prevent or relieve a cough is:
A) bronchodilator
B) rhinorrhea
C) antitussive
D) epiglottis
Q4) Pertaining to the windpipe is called _____.
Q5) A weak voice is referred to as _____.
Q6) A radiography of the bronchi is called a(n) _____.
Page 10
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Chapter 9: Digestive System
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Sample Questions
Q1) A disorder of carbohydrate metabolism that is characterized by high concentrations of sugar in the blood and results from insufficient production or utilization of insulin is called:
A) anorexia
B) diabetes mellitus
C) hypoglycemia
D) pancreatitis
Q2) The branch of medicine that specializes in the stomach, intestines, and associated structures is called:
A) gastroenterology
B) internal medicine
C) intestinology
D) proctology
Q3) Alimentation is:
A) improper absorption or distribution of food to the body
B) lack of proper food for normal body function
C) the abnormal condition that occurs when output of body fluid exceeds fluid intake
D) the process of providing nutrition for the body
Q4) _____ is defined as inflammation of the liver.
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Chapter 10: Urinary System
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Sample Questions
Q1) _____ means pertaining to the bladder.
Q2) Passage of a tubular, flexible instrument into a body channel or cavity for introduction or withdrawal of fluid is called:
A) catheterization
B) cystostomy
C) lithotripsy
D) tracheotomy
Q3) Cystoscopy is:
A) an instrument to view inside the bladder
B) cutting into a cyst
C) visual examination of the urinary bladder
D) excision of a cyst
Q4) The name of the functional unit of the kidney is:
A) glomerulus
B) nephron
C) tubule
D) ureter
Q5) A fiberoptic instrument for viewing the kidney is called a(n) _____.
Q6) Ketones in the urine is known as _____.
Q7) Filtering blood to maintain proper balance is called _____ or _____.
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Chapter 11: Reproductive System
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Sample Questions
Q1) Surgical puncture of the amnion is called:
A) amniotic
B) amniocentesis
C) amniotomy
D) cesarean section
Q2) A(n) _____ describes a woman who has never given birth.
Q3) A 32-year-old man underwent surgical fixation of an undescended testicle. This procedure is called an:
A) orchidectomy
B) orchidopexy
C) orchidoplasty
D) orchiotomy
Q4) A women who is pregnant may consider taking which types of vitamins?
A) antenatal
B) perinatal
C) postnatal
D) prenatal
Q5) _____ is defined as pertaining to a fetus.
Q6) The surgical repair of the vagina is referred to as _____.
Q7) _____ means painful menstruation.
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Chapter 12: Integumentary System
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Sample Questions
Q1) Which of the following statements is true of topical medications?
A) They are applied directly to the skin.
B) They are injected into the subcutaneous tissue.
C) They are injected just under the skin.
D) They are placed under the tongue.
Q2) A scraping or rubbing away of the skin is referred to as _____ or _____.
Q3) A common chronic skin disorder characterized by circumscribed red patches that are covered by thick, dry, silvery scales is called:
A) ichthyosis
B) pediculosis
C) psoriasis
D) xerosis
Q4) The term dermatitis means _____ skin.
A) dry
B) inflammation of the
C) scaly
D) wrinkling of the
Q5) An oily substance of sebaceous glands is referred to as _____.
Q6) _____ is defined as a fungal inflammation of the skin.
Q7) The outermost skin layer is the _____.
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Chapter 13: Nervous System and Psychologic Disorders
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Sample Questions
Q1) Inflammation of the bone marrow or inflammation of the spinal cord is called:
A) encephalomalacia
B) encephalopathy
C) parathyroidism
D) myelitis
Q2) Recording and analysis of the electrical activity of the brain is called:
A) electroencephalogram
B) electroencephalograph
C) electroencephalography
D) encephalopathy
Q3) A 31-year-old man wakes up and is unable to move his legs. Medical examination reveals there is no actual paralysis. He is diagnosed with hysterical paralysis, also known as:
A) diplegia
B) hemiplegia
C) pseudoplegia
D) tetraplegia
Q4) Softening of the brain is called _____.
Q5) Pain along the course of a nerve is referred to as _____.
Q6) A type of nerve that is considered the largest in the body is the _____ nerve.
Page 15
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Chapter 14: Special Sensory Organs of the Peripheral
Nervous System
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Sample Questions
Q1) Which surgical procedure is performed to correct ptosis?
A) blepharoplasty
B) cryoextraction
C) intraocular lens transplant
D) LASIK
Q2) Which term means capable of being heard?
A) accommodation
B) audible
C) aural
D) auricular
Q3) Nerve endings that detect chemicals are called:
A) chemoreceptors
B) nasolacrimal sacs
C) optic nerves
D) rods and cones
Q4) Which of the following refers to colorblindness?
A) achromatic vision
B) day vision
C) double vision
D) night vision
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Chapter 15: Endocrine System
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Sample Questions
Q1) An important female sex hormone that is made by the ovaries and acts on the female genitalia is:
A) adrenaline
B) androgen
C) epinephrine
D) estrogen
Q2) Increased blood sugar is:
A) glycosuria
B) hyperglycemia
C) polydipsia
D) polyuria
Q3) A(n) _____ is the removal of the thyroid gland.
Q4) A 62-year-old man needs to have the gland above his kidney removed. This surgery is called a(n):
A) adenectomy
B) adrenalectomy
C) parathyroidectomy
D) thyroidectomy
Q5) _____ is the term describing normal thyroid function.
Q6) Tumor of a gland is referred to as a(n) _____.
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