NWCA MEDICAL ASSISTANT QUESTIONS AND
ANSWERS SET A+
✔✔Triage - ✔✔Prioritization of patients according to their needs by assessing
symptoms, situations, and external factors. Triage is done directly with the patients that
come into the office as well as on the phone when patients call in to make an
appointment. The most important factor in triage is to listen carefully to what the patient
is saying. Let them finish telling you the details needed to make an assessment, as
each office will have a protocol for triage. You should follow this policy strictly because it
has been well thought out and tested. If you have any questions, ask the nurse or
physician in charge. Considerations for prioritizing patients are on this page.
Remember, the most immediate need should take the highest priority.
✔✔Consent - ✔✔In the patient-physician contract, there is a request for services,
provisions of that service, and compensation for the service. The patient can also
expect that the care the physician provides is reasonable, customary, and consistent
with what any prudent physician would do in the same situation and that the provider is
working within the scope of his or her training and practice. This does not guarantee a
good outcome; in many cases, the treatment does not work.
Consent is required in order for a physician to treat a patient. In a medical office where
a patient goes in for a visit with a physician, for routine examinations, consent is implied
(called implied consent) assuming that if the patient did not want to be examined, he or
she would not have visited the physician. Signed consent forms are required when the
physician wants to perform a specific procedure and when specific protected health
information must be released to another entity outside of the medical practice.
✔✔Implied Consent - ✔✔An agreement implied by the patient for examination and
treatment when presenting for a routine visit; also, in an emergency, consent that it is
assumed the patient would give if the patient could do so
✔✔Consent to Release Information - ✔✔Consent to Release Information is a
requirement based on the regulations of HIPAA. In order for the provider to release any
information to a third party, the patient must sign a form that includes:
,The name of the medical facility or practice that is releasing the information
The name of the individual who is going to receive the information
The patient's full name
The specific information that is going to be released
The purpose for the information
The date of the signature
The date the consent will expire
The signature of a witness to the patient signing the form
✔✔Informed Consent - ✔✔An ethical principle requiring that research participants be
told enough to enable them to choose whether they wish to participate.
✔✔Charting - ✔✔Process of documenting all of the events of a patient's visit and
related activities. The health professionals who are involved in the treatment of the
patient are responsible for charting. The patient's chart becomes a part of the overall
medical record providing much of the required content. Remember that a patient's
medical record, including the chart, is a legal document, and proper procedures must be
adhered to in terms of how information is entered, how it is corrected it there is a
mistake, how it is stored, and how it is released to other entities. All entries into the
patient's chart must follow the policies and procedures of the medical facility. There is
no room for personal style or options in charting
✔✔Patient History and Completing a Patient History Form - ✔✔Medical assistants are
commonly asked to take a medical history each time the patient visits the office. A
patient's history
should include the information here.
✔✔Charting a clinical visit - ✔✔Ensure that you have selected the correct chart for the
patient. Verify the patient's name and birth date.
Remember that there may be more than one individual with the same name, so ensure
that you have the right patient.
If making entries into a paper chart, print legibly using black or blue ink. Red ink is
acceptable for allergies at some facilities.
Ensure that the patient's name is on each page of the chart in case the file is
disassembled and the papers become loose.
,Date and initial every entry.
Write brief but complete entries.
Use only acceptable medical abbreviations and terminology. Make sure that medical
terms are spelled correctly.
Never erase or whiteout mistakes. Draw a line through a mistake so that the original
entry is legible. Write the word "error" above the mistake. Initial and date the correction.
Then, enter the correct information and sign the
completed entry.
Document all phone conversations with the patient or patient's significant other including
any action you take or recommendation you give the patient.
Document all missed appointments.
✔✔Charting Abbreviations - ✔✔Given that abbreviations can lead to confusion in
healthcare, or even errors in patient care, medical assistants must be extremely careful
when using abbreviations in patients' charts and ensure that the abbreviations are
accepted by their facilities. Patient charts must use commonly accepted medical terms
and abbreviations.
✔✔Charting Abbreviations - ✔✔C C Chief Complaint
C P R Computerized Patient Record
D S Discharge Summary
D X Diagnosis
E H R Electronic Health Record
E M R Electronic Medical Record
E P R Electronic Patient Record
F H Family History
H & P History And Physical Examination
HIPPA Health Insurance Portability and Accountability Act
H P I History Of Present Illness
, P E Physical Examination
P M H Past Medical History
R O S Review Of Systems
S H Social History
✔✔Gowning - ✔✔Remove everything from the waste up, including bra, Jewelry,
piercings, etc. put gown on, open to the back
✔✔Patient Positioning and Draping - ✔✔The medical assistant who is assisting in a
surgical procedure is responsible for positioning and draping the patient for the
procedure. This takes place before the local anesthesia is administered. You will
position the patient in a specific way to ensure that the patient is supported
appropriately and the area for the surgery is exposed sufficiently for the physician to
complete the procedure. Your job is to identify the patient using the protocol of the
facility, escort the patient into the treatment room, assist the patient onto the
examination table, and help the patient get comfortable. You may use pillows or towels
to provide additional support.
Once the patient is in the proper position, place a drape, sheet, or blanket over any
exposed areas to provide warmth and preserve the patient's dignity. In some cases, a
general anesthesia will be used.
The patient will be asleep for the final positioning and draping. Be sure to pay attention
to any disabilities the patient has and make appropriate accommodations.
A sterile drape is required for draping the patient and the surgical site; it provides a
sterile field for the procedure so that the physician can work without risk to the sterile
field. Drapes are made of sterile
muslin cloth or paper with a vinyl or plastic backing. They come in many different sizes
and colors. Fenestrated drapes have a slit or hole that exposes the surgical area.
✔✔Anatomical Position - ✔✔A standing position with feet together and palms facing
outward. This is the typical position for examination of male patient's genitals and for
assessment for inguinal hernia. The physician may also perform a screening test for
scoliosis in this position.
✔✔Sitting - ✔✔Many patient examinations begin with the patient in a sitting position on
the exam table. Patient is to sit with legs hanging over the side of the exam table. The
physician typically keeps the patient in this position for auscultation of heart and lungs
and for examination of the head, eyes, ears, nose, and throat. Parts of the neurological
exam are also performed in this position. Any drape should be on the lap and legs.
✔✔Fowler's - ✔✔The Fowler's position requires the patient to sit erect on the table with
the legs extended in front and the backrest positioned at a 90-degree angle to the table.
ANSWERS SET A+
✔✔Triage - ✔✔Prioritization of patients according to their needs by assessing
symptoms, situations, and external factors. Triage is done directly with the patients that
come into the office as well as on the phone when patients call in to make an
appointment. The most important factor in triage is to listen carefully to what the patient
is saying. Let them finish telling you the details needed to make an assessment, as
each office will have a protocol for triage. You should follow this policy strictly because it
has been well thought out and tested. If you have any questions, ask the nurse or
physician in charge. Considerations for prioritizing patients are on this page.
Remember, the most immediate need should take the highest priority.
✔✔Consent - ✔✔In the patient-physician contract, there is a request for services,
provisions of that service, and compensation for the service. The patient can also
expect that the care the physician provides is reasonable, customary, and consistent
with what any prudent physician would do in the same situation and that the provider is
working within the scope of his or her training and practice. This does not guarantee a
good outcome; in many cases, the treatment does not work.
Consent is required in order for a physician to treat a patient. In a medical office where
a patient goes in for a visit with a physician, for routine examinations, consent is implied
(called implied consent) assuming that if the patient did not want to be examined, he or
she would not have visited the physician. Signed consent forms are required when the
physician wants to perform a specific procedure and when specific protected health
information must be released to another entity outside of the medical practice.
✔✔Implied Consent - ✔✔An agreement implied by the patient for examination and
treatment when presenting for a routine visit; also, in an emergency, consent that it is
assumed the patient would give if the patient could do so
✔✔Consent to Release Information - ✔✔Consent to Release Information is a
requirement based on the regulations of HIPAA. In order for the provider to release any
information to a third party, the patient must sign a form that includes:
,The name of the medical facility or practice that is releasing the information
The name of the individual who is going to receive the information
The patient's full name
The specific information that is going to be released
The purpose for the information
The date of the signature
The date the consent will expire
The signature of a witness to the patient signing the form
✔✔Informed Consent - ✔✔An ethical principle requiring that research participants be
told enough to enable them to choose whether they wish to participate.
✔✔Charting - ✔✔Process of documenting all of the events of a patient's visit and
related activities. The health professionals who are involved in the treatment of the
patient are responsible for charting. The patient's chart becomes a part of the overall
medical record providing much of the required content. Remember that a patient's
medical record, including the chart, is a legal document, and proper procedures must be
adhered to in terms of how information is entered, how it is corrected it there is a
mistake, how it is stored, and how it is released to other entities. All entries into the
patient's chart must follow the policies and procedures of the medical facility. There is
no room for personal style or options in charting
✔✔Patient History and Completing a Patient History Form - ✔✔Medical assistants are
commonly asked to take a medical history each time the patient visits the office. A
patient's history
should include the information here.
✔✔Charting a clinical visit - ✔✔Ensure that you have selected the correct chart for the
patient. Verify the patient's name and birth date.
Remember that there may be more than one individual with the same name, so ensure
that you have the right patient.
If making entries into a paper chart, print legibly using black or blue ink. Red ink is
acceptable for allergies at some facilities.
Ensure that the patient's name is on each page of the chart in case the file is
disassembled and the papers become loose.
,Date and initial every entry.
Write brief but complete entries.
Use only acceptable medical abbreviations and terminology. Make sure that medical
terms are spelled correctly.
Never erase or whiteout mistakes. Draw a line through a mistake so that the original
entry is legible. Write the word "error" above the mistake. Initial and date the correction.
Then, enter the correct information and sign the
completed entry.
Document all phone conversations with the patient or patient's significant other including
any action you take or recommendation you give the patient.
Document all missed appointments.
✔✔Charting Abbreviations - ✔✔Given that abbreviations can lead to confusion in
healthcare, or even errors in patient care, medical assistants must be extremely careful
when using abbreviations in patients' charts and ensure that the abbreviations are
accepted by their facilities. Patient charts must use commonly accepted medical terms
and abbreviations.
✔✔Charting Abbreviations - ✔✔C C Chief Complaint
C P R Computerized Patient Record
D S Discharge Summary
D X Diagnosis
E H R Electronic Health Record
E M R Electronic Medical Record
E P R Electronic Patient Record
F H Family History
H & P History And Physical Examination
HIPPA Health Insurance Portability and Accountability Act
H P I History Of Present Illness
, P E Physical Examination
P M H Past Medical History
R O S Review Of Systems
S H Social History
✔✔Gowning - ✔✔Remove everything from the waste up, including bra, Jewelry,
piercings, etc. put gown on, open to the back
✔✔Patient Positioning and Draping - ✔✔The medical assistant who is assisting in a
surgical procedure is responsible for positioning and draping the patient for the
procedure. This takes place before the local anesthesia is administered. You will
position the patient in a specific way to ensure that the patient is supported
appropriately and the area for the surgery is exposed sufficiently for the physician to
complete the procedure. Your job is to identify the patient using the protocol of the
facility, escort the patient into the treatment room, assist the patient onto the
examination table, and help the patient get comfortable. You may use pillows or towels
to provide additional support.
Once the patient is in the proper position, place a drape, sheet, or blanket over any
exposed areas to provide warmth and preserve the patient's dignity. In some cases, a
general anesthesia will be used.
The patient will be asleep for the final positioning and draping. Be sure to pay attention
to any disabilities the patient has and make appropriate accommodations.
A sterile drape is required for draping the patient and the surgical site; it provides a
sterile field for the procedure so that the physician can work without risk to the sterile
field. Drapes are made of sterile
muslin cloth or paper with a vinyl or plastic backing. They come in many different sizes
and colors. Fenestrated drapes have a slit or hole that exposes the surgical area.
✔✔Anatomical Position - ✔✔A standing position with feet together and palms facing
outward. This is the typical position for examination of male patient's genitals and for
assessment for inguinal hernia. The physician may also perform a screening test for
scoliosis in this position.
✔✔Sitting - ✔✔Many patient examinations begin with the patient in a sitting position on
the exam table. Patient is to sit with legs hanging over the side of the exam table. The
physician typically keeps the patient in this position for auscultation of heart and lungs
and for examination of the head, eyes, ears, nose, and throat. Parts of the neurological
exam are also performed in this position. Any drape should be on the lap and legs.
✔✔Fowler's - ✔✔The Fowler's position requires the patient to sit erect on the table with
the legs extended in front and the backrest positioned at a 90-degree angle to the table.
