TL;DR
Master proper documentation practices including accurate charting, reporting changes, and maintaining medical records. Documentation is a legal requirement and a frequently tested competency.
Free Medical Records & EHR Practice Questions
Medical Assistant Certification (CMA/RMA) · Administrative Procedures
This module covers Medical Records & EHR as part of the Administrative Procedures section, testing your understanding of core concepts and their practical application.
| Exam | Medical Assistant Certification (CMA/RMA) |
| Pass Rate | 72% |
| Duration | 160 minutes |
| Module | Medical Records & EHR |
Why Medical Records & EHR matters
Medical Records & EHR is a commonly tested topic on the Medical Assistant Certification (CMA/RMA) because it covers fundamental knowledge required for competent professional practice.
Sample Practice Questions (5)
1. In a SOAP note, a patient's statement "I've had a headache for 3 days" is documented in which section?
- Subjective (S)
- Objective (O)
- Assessment (A)
- Plan (P)
2. In problem-oriented medical records (POMR), patient information is organized by:
- Each identified problem or diagnosis, with notes grouped under the corresponding problem number
- The source of the information (laboratory, radiology, progress notes) in separate sections
- Chronological order only, regardless of the medical condition
- Alphabetical order of the patient's diagnoses
3. Electronic prescribing (e-prescribing) offers which advantage over handwritten prescriptions?
- Automatic drug interaction and allergy checking, improved legibility, and reduced medication errors
- Elimination of the need for patient consent before prescribing
- Automatic dispensing of medications without pharmacist review
- Removal of the requirement for DEA registration for controlled substances
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Start practicing free →4. A patient's EHR contains the following entry: "Patient appears to be drug-seeking and is probably lying about pain level." This entry is problematic because:
- It should have been entered in the Plan section of the SOAP note
- It contains subjective opinions and judgmental language that is inappropriate for clinical documentation
- The medical assistant is not allowed to document anything about patient behavior
- Pain assessments should never be included in the medical record
5. A patient requests a complete copy of their medical records. Under HIPAA, the practice must provide the records within:
- 30 days of the request, with a possible 30-day extension if needed
- 72 hours of the request with no exceptions
- 90 days of the request
- 7 business days of the request
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