vitals
average tempeture
98.6
If you didnt document is it didnt__
happen
what are some of the characteristics of a chief complaint
onset , location, duration character, severity, timing, alleviating/ aggravation factors
When a patient's blood pressure is unexpectedly high, what's the first step a medical assistant should take before notifying the provider?
Recheck the blood pressure to confirm accuracy
What does the "S" in SAMPLE stand for?
Signs and Symptoms
average pulse range for an infant
80-140
what color ink can be use
blue and black
which characteristic of a chief complaint would this question fall under " when did the symptoms start"
durations
Why is it important to consider a patient's baseline vital signs when interpreting new results?
Because deviations from baseline can indicate early signs of a problem even if values are still "normal"
In the OPQRST assessment tool, what does the "p" help determine?
Provocation or Palliation - what makes the symptom better or worse
what is considered stage 1 hypertension in a adult
Systolic 130-139
diastolic 80-89
If you make a mistake when documenting how do you correct it
Single line through and initials
what is the first thing a provider should see on a chief complaint
why the patient is here
A patient reports dizziness when standing up. What critical thinking step should the MA take next?
Assess for orthostatic changes — take vital signs lying, sitting, and standing
When using SAMPLE, what type of information is gathered under "M"?
Medications the patient is currently taking
what is the normal 02 saturation in an adult
between 95% and 100%
acceptable documentation
a medical record that is accurate, correct, legible, chronological account of the care provided to the patient.
what category would the question " how often does it occur?"
timing
If a patient's symptoms don't match their stated chief complaint, what should the medical assistant do?
Ask clarifying questions and document objective observations to help the provider evaluate further
In OPQRST, what does "Q" stand for, and what type of question might you ask for it?
Quality — ask "Can you describe the pain? Is it sharp, dull, burning,
Average respiration in an infant (birth -1 years old)
30-60
What are common documentation errors made by healthcare professionals, and how can they be avoided?
Omitting important details (e.g., medication changes, vital signs)
Late entries without proper time stamps
Using unapproved abbreviations
Subjective or biased language
what category would "how long has the symptoms been present?" fall under
duration
When gathering history, why is it important to prioritize questions based on the patient's condition?
To ensure urgent or life-threatening issues are identified and addressed first
The "E" in SAMPLE is often the last thing you ask about. What does it stand for, and why is it important?
Events leading up to the illness or injury — helps identify the context and possible cause