Vital signs
What vital signs measures the heartbeats per minute?
Pulse
What does CC stand for in a medical record?
Chief complaint.
What does the "S" in SAMPLE stand for?
Symptoms
What should documentation always be?
Accurate, objective, and complete.
What term means listening to sounds inside the body with a stethoscope?
Auscultation.
A normal adult respiratory rate is usually between what range?
12-20 Breaths per minute.
A patient says, "My stomach hurts". What follow-up questions helps gather more information?
Ask where the pain is located and when it started.
What does the "O" in OPQRST stand for?
Onset.
Should a medical assistant document personal opinions about a patient?
No, documentation should include only facts.
What term means using sight to examine patient.
Inspection.
A patient has oxygen saturation of 88%.
What should the Medical Assistant do?
Report the abnormal finding to the provider immediately.
What is the best example of a chief complaint?
A. "patient has influenza."
B. "Patient reports sore throat for 3 days."
B. "Patient reports sore throat for 3 days."
A patient say pain started suddenly after exercising. Which OPQRST section is this?
Onset.
Which statement is correctly documented.
A. "Pt seems lazy."
B. "Pt reports feeling tired."
B. Patient reports feeling tired.
A patient refuses a procedure because they are nervous. What should the MA do?
Explain the procedure, provide reassurance, and notify the provider if needed.
A patients Blood Pressure is 180/110 mmHg. What condition does this indicate?
Hypertension (High Blood Pressure).
A Pt reports chest pain. Which OPQRST question asks how the pain feels?
Quality ( Q )
A patient reports abdominal pain. The MA asks, "Where is the pain located, and does it move anywhere else?" Which OPQRST category is being assessed?
Region/Radiation.
Why is proper documentation important?
It provides a legal record and helps guide patient care.
A patient arrives with shortness of breath, chest pain, and anxiety. The waiting room is full. What should the MA do using critical thinking?
Recognize the patient may need urgent care, obtain vitals signs an notify the provider immediately.
A patient arrives pale, confused, and has a pulse of 130 bpm and low blood pressure. What is the MA's priority action?
Take vital signs, assess the patient, and notify the provider immediately.
A Pt says, " I have headaches." What additional information should the MA collect before the provider visit?
Location, severity, duration, symptoms, and what makes it better or worse.
A patient is brought into the clinic after fainting. The MA asks, "What happened before you passed out?" and "When was the last time you ate or drank?" Which two parts of SAMPLE is the MA assessing?
Events leading up to the problem and last oral intake.
A Patient says, "My pain is unbearable" How should the MA document this?
Document the patient's exact words and include objective findings.
A patients vital signs are abnormal. The MA should?
A. Ignore it
B. Document and report it
C. Diagnose the problem.
B. Document and report it.