Medical Assistant & Charting Flashcards
What is a Medical Assistant?
a person that functions under the supervision of a licensed professional working in administrative and clinical settings
What is within a Medical Assistant’s scope of practice?
taking medical history
take vital signs
explaining procedures
preparing patients for exam
assistant physician during exam
collect and prepare specimens
Define Scope of Practice
The type of care you can provide based on your qualifications
Medical History
A record of the patient’s past and current health
Chief Complaint (CC)
Reason for visiting the physician’s office
SOAPER
subjective, objective, assessment, plan, education, response
CHEDDAR
chief complaint, history of present illness examination, details, drugs and dosages, assessment, return visit information or referral.
Patient Record
Important information about a patient’s medical history and present condition.
Define and Name The Types of Progress Note
brief note from a physician documenting a patient’s progress
SOAPER & CHEDDAR
Source Oriented Medical Record (SOMR)
a record that is organized by data source or subject
Problem Oriented Medical Record (POMR)
A record organized according to a patient’s specific health problems
Autonomy
The ability for patient to choose what works in their best interest
Confidentiality
Keeping information private
Family History (FHx)
health of blood relative that could alert the physician to hereditary or familial diseases
Social History (SHx)
marital status, occupation, educational attainment, alcohol & tobacco/drug use; lifestyle
