Medical Assistant Clinical Procedures
Chapter 1 Exam Q&A
Electronic Medical Record (EMR) - ANSWER-computerized record of the important
information regarding a patient
Optical Character Recognition (OCR) - ANSWER-manually scanning records in
digital format
Health History Report - ANSWER-collection of subjective data about the patient
Diagnosis - ANSWER-scientific method of determining and identifying a patient's
condition
Chief Complaint - ANSWER-the symptom that is causing the patient the most trouble
Foundation for the more detailed the present illness and review of systems sections.
MA's responsible for obtaining the CC
(-an open-ended question
-Limited to one or two symptoms
-Concisely and briefly using PT's own words
-Duration of symptoms)
Present Illness - ANSWER-an expansion of the chief complaint, includes a full
description of the patients current illness from the time of its onset
Past Medical History - ANSWER-review of patients past medical status
-Major Illnesses
-Childhood diseases
-Unusual infections
-Accidents and Injuries
-Hospitalizations and operations
-Previous medical tests
-Immunizations
-Allergies m-Current medications
Family History - ANSWER-review of health status of patients blood relatives
Focuses on diseases that tend to be familial
Ex. Hypertension, heart disease, allergies, and diabetes mellitus
Chapter 1 Exam Q&A
Electronic Medical Record (EMR) - ANSWER-computerized record of the important
information regarding a patient
Optical Character Recognition (OCR) - ANSWER-manually scanning records in
digital format
Health History Report - ANSWER-collection of subjective data about the patient
Diagnosis - ANSWER-scientific method of determining and identifying a patient's
condition
Chief Complaint - ANSWER-the symptom that is causing the patient the most trouble
Foundation for the more detailed the present illness and review of systems sections.
MA's responsible for obtaining the CC
(-an open-ended question
-Limited to one or two symptoms
-Concisely and briefly using PT's own words
-Duration of symptoms)
Present Illness - ANSWER-an expansion of the chief complaint, includes a full
description of the patients current illness from the time of its onset
Past Medical History - ANSWER-review of patients past medical status
-Major Illnesses
-Childhood diseases
-Unusual infections
-Accidents and Injuries
-Hospitalizations and operations
-Previous medical tests
-Immunizations
-Allergies m-Current medications
Family History - ANSWER-review of health status of patients blood relatives
Focuses on diseases that tend to be familial
Ex. Hypertension, heart disease, allergies, and diabetes mellitus
