Vital Signs
The normal adult resting heart rate range.
What is 60 to 100 beats per minute?
Before beginning an assessment, you should verify these two pieces of patient information.
What is the patient's name and date of birth (DOB)?
What does the medical abbreviation "NPO" stand for.
What is "nothing by mouth"?
A nurse asks, "Did this pain start suddenly, and how long has it lasted?"
What are Onset and Time?
A patient rates their pain as 9/10. Do you record it even if they do not look uncomfortable.
What is yes?
The normal range for adult oxygen saturation on room air.
What is 95% to 100%?
During history taking, you should ask about these to help prevent adverse reactions and identify current treatments.
What is allergies and medications?
Legally, who owns the physical health records.
What is the medical facility/provider?
What does the "A" and "M" stand for in SAMPLE?
What are Allergies and Medications?
A patient asks you to tell their friend about their diagnosis. What must be obtained first.
What is written permission?
The medical term for a heart rate under 60 beats per minute.
What is bradycardia?
When we hear this, the patient becomes our top priority.
What is chest pain?
The section in a SOAP note where a patient self-reports pain.
What is the subjective section?
Clue: A doctor asks, "Is your chest pain sharp, dull, squeezing, or crushing?"
What is Quality?
A patient becomes short of breath while walking to the exam room.
What is dyspnea?
The medical term for a body temperature above 100.4°F.
What is a fever (or pyrexia)?
This term describes how intense or serious a patient's symptom is, often rated on a scale from 0 to 10.
What is pain?
Standard professional procedure to correct an error made on a medical record.
What is to draw a single line through the error, and initial it?
The letter in OPQRST you are checking when you ask, "Does the pain move?"
What is R (Radiation)?
A patient denies smoking but reports vaping nicotine daily.
What is to document on nicotine use?
A blood pressure over 180 systolic or 120 diastolic.
What is a hypertensive crisis?
This type of data includes symptoms and information reported directly by the patient.
What is subjective data?
The difference between the "Chief Complaint (CC)" and the "History of Present Illness (HPI)" in a patient's intake documentation.
What is the main reason (CC) and a detailed story (HPI)?
The letter in SAMPLE you check by asking when the patient last ate.
What is L (Last oral intake)?
A patient has chest pain, shortness of breath, and dizziness. The MA should:
What is notify the provider immediately?