The Pressure's On 🩺
What is the normal respiratory and Oxygen rate for adults?
12-20 bpm, 95%-100%
What is a chief complaint?
The main reason the patient seeks medical health.
What does the S stand for in SAMPLE?
Signs and symptoms
What is an Electronic Health record EHR?
This is type of charting records patient information directly into an electronic computer.
A patient C/O chest pain , shortness of breath, and sweating these symptoms may indicate what ?
Heart attack (Myocardial infarction)
A patient has a pulse of 120 bpm while resting. Is this normal or abnormal?
Abnormal (tachycardia)
What type of language should be avoided when recording a chief complaint?
Curse words and Assumptions
Patients should state this part of their visit in their own words.
Chief complaint
Why is accurate documentation important in healthcare?
For legal records, patient safety, and communication with healthcare team
This position is commonly used for pelvic examinations.
Lithotomy
This device measures the oxygen in patients blood
pulse oximeter
This component refers to symptoms spreading to another area.
Radiation
When gathering social history, you should ask about these three substance categories.
Tobacco, alcohol, and drugs
What do you do if a "patient refused"?
If a patients refuses the medical assistant should document this and include the reason if provided
What is sims position and what exam is mainly used for?
This position requires the patient to lie on their side with the upper leg bent, often used for rectal exams.
A patient's temperature is 39°C. What does this indicate?
Febrile (fever)
A 60 year old man reports crushing chest pain radiating to his left arm and jaw, accompanied by sweating and shortness of breathe. His symptoms started while climbing stairs .
heart attack
What is the past medical history?
Refers to medical conditions the patient has been diagnosed in the past
This law requires healthcare providers to obtain written permission before sharing patient health information.
HIPAA
This method involves tapping the body to evaluate sound differences.
Percussion
This abnormal pulse condition occurs when the rhythm of the heartbeat is irregular.
Arrhythmia
These are factors that make the symptom better.
Alleviating factors
What are events leading up to the illness or injury began?
Events that happened right before illness or injury began .
This type of information includes details about a patient’s tobacco, alcohol, and drug use.
Social History
What is stethoscope?
This instrument is used to listen to heart, lung, and bowel sounds