Vital Signs
What is the normal adult body temperature?
98.6 F (37 C)
What does CC stand for?
Chief Complaint
Patient’s previous medical and surgical information
medical history
What color ink is used in medical records?
Black ink
Most critical skill for a MA?
Great communication skills
What term describes a slow heart rate below 60 bpm?
Bradycardia
What is a Chief Complaint?
The reason for the visit
What are the 5 components to health history?
Chief complaint, history of present illness, medical history, family history, personal and social history
What law protects patient information?
HIPAA
Why is observation important for critical thinking?
It helps identify changes in a pts condition
What vital signs is most affected during dehydration?
Heart rate (pulse increases)
When is the Chief Complaint taken?
At the beginning of the visit
Systematic assessment if all body systems for abnormalities, and can identify signs and symptoms associated with the cc and problems not related to the cc
review of system
Why is documentation important?
For protection and privacy
What does a MA do when vitals are abnormal?
Recheck the vitals and report the results to the provider
What is the normal oxygen saturation range for most healthy adults?
95-100%
What type of questions do you ask the patient?
Open-ended questions
What are the 7 components to personal and social history?
Marital status and support, habits, self-care, sexual history, home conditions, occupation, and religious preference
What must every entry include?
Every single entry must include demographics?
How can MA’s improve their critical thinking skills?
Engaging in clinical scenarios, ask questions, and practice self-reflection
Scenario:
Patient vitals:
BP: 90/60
Pulse: 115 bpm
Respirations: 22
SpO₂: 95%
Question:
What two vital signs are abnormal?
Pulse and blood pressure
You record the CC in the patients____
Own words
What are the 10 components in the medical and surgical history?
medications, allergies, transfusions, screening, chronic conditions, past diagnoses, immunizations, past surgical, procedures, serious injuries, and functional limitations
What does SOAP stand for?
Subjective, Objective, Assessment, Plan
Key critical thinking skills for MA’s
Attention to detail, active listening, problem-solving, decision-making, and adaptability