Vital Signs
What does a blood pressure reading of 140/90 mmHg indicate?
Stage 1 hypertension
When do MA's gather chief complaints?
After asking for the patient identifiers.
What is the first thing documented after recording the patient's Chief Complaint?
2 Patient identifiers (Full name and DOB)
Describe Chief Complaint
The primary piece of information an MA needs, to find out the reason for the visit.
A patient comes in complaining of chest pain. What do you do?
What vital signs should be taken for the full minute if irregular?
Respirations and Pulse.
What is duration?
This part of the chief complaint describes how long symptoms have been present.
What are somethings to avoid when documenting?
Rewording what a patient says.
These include conditions like diabetes, asthma, and heart disease that the patient has been diagnosed with in the past.
Past Medical History.
You see a colleague place a dirty needle on the counter instead of the sharps container. What do you do?
Place needle in sharps handling the needle properly. Remind them of the dangers of leaving a dirty needle out. Notify supervisor if it keeps happening.
Why it is important to establish a patient's baseline pulse rate before any medical procedures?
To help assess the cardiovascular system, and identify possible risk factor.
What is subjective data?
This is the term for information the patient reports that cannot be measured directly, such as dizziness, and pain.
What is the first thing you should ask a patient after they state their CC?
-When did the symptoms begin?
What does the Social History include.
This category includes lifestyle information such as smoking, alcohol use, drug use, occupation, and living situation.
A man comes in visibly upset, starts yelling at the MA, demanding to know what time his wife's appointment was. He is not listed on the HIPAA Disclosure form. What do you tell the husband?
Let him know you cannot give out the information, and let him know to talk to his wife about the the disclosure form. If things escalate talk to the office manager and have his escorted.
A patient present with an SPO2 reading of 88%. Based on this information, what would be the most appropriate initial action for the healthcare provider?
Administer supplemental oxygen immediately.
What are open-ended questions?
This type of question encourages the patient to explain their symptoms in their own words, such as “Tell me more about the pain.”
What is an addendum? What does it include?
A correction in an EHR. Includes, date and time of correction, and initials of the person correcting it.
What is the current medication list?
This part of the patient history includes prescription drugs, over-the-counter medications, vitamins, and herbal supplements, and must include the name, dose, and how often each is taken.
A patient's family asks you to keep a diagnosis from the patient, but the patient is competent and has the right to know their own health status.What should you do.
As the medical assistant you must respect patient autonomy and ensure that the patient has access to the information needed to make informed decisions about their own healthcare.
What temperature is considered hypothermia?
Anything below 95 degrees F
What is to document the complaint accurately using the patient’s own words?
This is the first step a medical assistant should take after hearing the patient state their chief complaint.
When a provider gives a verbal order, due to lack of time to write the order down. What is the correct documentation response while staying within MA scope of practice?
When should Surgical history be provided. Which one needs to be included for women?
This part of the history includes previous operations — and must ALWAYS include. C-sections are a part of surgical history.
Patient comes in with signs of abuse. Patient claims they had an accident and fell. Patient refuses to make eye contact and barley says a word. What steps do you take as an MA.
As an MA, you cannot diagnose, or interrogate. Ask the questions needed, in a private room. If the patient refuses, let provider know. Only document what the patient says.