Medical Assistant Clinical Procedures
Chapter 1
Medical Record - correct answer ✔written record of important information
regarding patient
Paper-Based Patient Records (PPRs) - correct answer ✔paper medical
records
Electronic Medical Record (EMR) - correct answer ✔computerized record of
the important information regarding a patient
Optical Character Recognition (OCR) - correct answer ✔manually scanning
records in digital format
Health History Report - correct answer ✔collection of subjective data about
the patient
Diagnosis - correct answer ✔scientific method of determining and identifying
a patient's condition
Chief Complaint - correct answer ✔the symptom that is causing the patient
the most trouble
Present Illness - correct 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 - correct answer ✔review of patients past medical
status
Family History - correct answer ✔review of health status of patients blood
relatives
Familial Disease - correct answer ✔condition that occurs in or affects blood
relatives more frequently that would be expected by change
Social History Section - correct answer ✔includes information on patients
lifestyles
Review of Systems (ROS) - correct answer ✔systematic review of each body
system to detect any symptoms that have not yet been revealed
Documenting - correct answer ✔process of recording information about a
patient in the medical record
Symptom - correct answer ✔any change in the body or its functioning that
indicated the presence of disease
Subjective Symptom - correct answer ✔felt by the patient, cannot be seen by
another person
Objective Symptom - correct answer ✔seen by another person and the
patient
Diaphoresis - correct answer ✔excessive perspiration
Chapter 1
Medical Record - correct answer ✔written record of important information
regarding patient
Paper-Based Patient Records (PPRs) - correct answer ✔paper medical
records
Electronic Medical Record (EMR) - correct answer ✔computerized record of
the important information regarding a patient
Optical Character Recognition (OCR) - correct answer ✔manually scanning
records in digital format
Health History Report - correct answer ✔collection of subjective data about
the patient
Diagnosis - correct answer ✔scientific method of determining and identifying
a patient's condition
Chief Complaint - correct answer ✔the symptom that is causing the patient
the most trouble
Present Illness - correct 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 - correct answer ✔review of patients past medical
status
Family History - correct answer ✔review of health status of patients blood
relatives
Familial Disease - correct answer ✔condition that occurs in or affects blood
relatives more frequently that would be expected by change
Social History Section - correct answer ✔includes information on patients
lifestyles
Review of Systems (ROS) - correct answer ✔systematic review of each body
system to detect any symptoms that have not yet been revealed
Documenting - correct answer ✔process of recording information about a
patient in the medical record
Symptom - correct answer ✔any change in the body or its functioning that
indicated the presence of disease
Subjective Symptom - correct answer ✔felt by the patient, cannot be seen by
another person
Objective Symptom - correct answer ✔seen by another person and the
patient
Diaphoresis - correct answer ✔excessive perspiration
