Vital Signs
This is the normal range for an adult's resting heart rate, measured in beats per minute.
What is 60 to 100 beats per minute?
This is the medical term for a symptom that occurs in addition to the chief complaint.
What are associated symptoms?
The observing, measuring, and examining of the patient is part of what in SOAP.
what is the Objective?
This is how a patient's own words should be recorded in documentation.
what is quoting directly, within quotation marks.?
When a patient presents with chest pain, shortness of breath, and dizziness, this is the most important vital sign to assess immediately.
What is blood pressure?
This device is used to measure blood pressure and consists of an inflatable cuff and a manometer.
What is a sphygmomanometer?
This assessment involves asking the patient if they've experienced similar symptoms or ever having this type of problem in the past.
What is the patients past medical history?
This part of history focuses on habits like smoking, alcohol use, and living situations.
What is social history?
This is how an error should be corrected in medical documentation.
What is drawing a single line through the error, then date, sign, and correct it?
You notice that a patient's blood pressure reading is consistently elevated, but they don’t show any symptoms. This should be your next step as a medical assistant.
What is recording the readings, informing the physician, and monitoring the patient regularly?
A temperature reading above 100.4°F in adults is considered this.
What is a fever?
This is why the chief complaint is important.
What is guiding diagnosis and treatment?
This is the recording of the pt’s main reason for seeking care, written in their own words and question marks.
What is the chief complaint?
This is how a patient's vital signs should be documented.
What are numerical values and unites?
A patient with a history of hypertension arrives for a routine checkup. During the visit, you notice their pulse is irregular. This is how you should proceed?
What is documenting the irregular pulse and notifying the physician?
This is the term for the high pressure reading in a blood pressure measurement, typically recorded when the heart contracts.
What is systolic pressure?
This aspect of the assessment asks whether anything the patient does makes their symptoms better or worse.
What are aggravating factors?
This is repeating back the pt’s words to show understanding.
What is reflection or paraphrasing?
This is the primary purpose of medical documentation.
What is ensuring continuity of patient care?
If you are measuring an adult's body temperature with an oral thermometer, and the reading is 99.5°F, this is the most likely explanation.
What is a normal body temperature? (Note: 98.6°F is average, but individual variations exist.)
This method of taking temperature involves placing a thermometer in the ear canal.
What is tympanic temperature measurement?
This is the type of questions you should ask your patients to get them to elaborate on their thoughts and feelings.
What are open-ended questions?
This acronym guides rapid emergency history by asking about Symptoms, Allergy, Medication, Past medical history, Last oral intake, Events leading up to illness or injury.
What is SAMPLE?
This is how abbreviations should be used in medical documentation.
What is being standardized, institution-approved, and clear?
A patient is showing signs of hypoxia (low oxygen levels), such as confusion and shortness of breath. This vital sign would be most helpful in assessing this condition.
What is pulse oximetry (SpO2)?