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Certified Medical Assistant — Practice Exam

Medical records: practice questions

Our Medical Assistant bank has 10 questions on this topic. Here are 4 of them with answers; the full mock exam draws from every topic, like the real one.

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Question 1

What does 'If it wasn't documented, it wasn't done' mean?

  1. Documentation is optional for routine care
  2. Providers should only document the services that are billed to insurance
  3. Care that isn't recorded can't be shown to have happened
  4. Patients must sign every entry in their chart
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C. Care that isn't recorded can't be shown to have happened — Accurate documentation matters for care, billing and legal protection.

Question 2

What does 'source-oriented' charting mean?

  1. Information is grouped by each of the patient's problems
  2. Information is kept only on paper and never electronically
  3. Information is grouped by its source, such as lab results or progress notes
  4. Information is written only by the patient
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C. Information is grouped by its source, such as lab results or progress notes — Each section of the chart holds one type of document.

Question 3

Under HIPAA, how quickly must a provider generally respond to a patient's request for access to their records?

  1. Within 24 hours of receiving the written request
  2. Within 6 months of receiving the written request
  3. Only when the patient's balance has been paid
  4. Within 30 calendar days (one 30-day extension may be allowed)
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D. Within 30 calendar days (one 30-day extension may be allowed) — Providers can't deny access because of unpaid bills.

Question 4

What is the minimum necessary standard under HIPAA?

  1. Collect as much information as possible from each patient
  2. Use or share only the PHI needed for the purpose
  3. Keep records for the minimum time allowed by law
  4. Give patients the minimum information about their care
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B. Use or share only the PHI needed for the purpose — It does not apply to disclosures for treatment.

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