Certified Medical Assistant (CMA AAMA)Communication and Legal/EthicalEasy
A medical assistant is documenting a patient's visit in the electronic health record. The patient reported experiencing 'sharp, stabbing pain' in their lower back. Which of the following should the medical assistant accurately record in the patient's chart?
- APatient complains of back pain, likely musculoskeletal in origin.
- BPatient states 'sharp, stabbing pain' in lower back.
- CPatient appears to be in significant pain in the lumbar region.
- DPatient reports severe lower back pain, probably disc-related.
Show answer & explanationAnswer & explanation
Correct answer: B. Patient states 'sharp, stabbing pain' in lower back.
Accurate documentation requires recording the patient's exact words (subjective information) or objective observations without interpretation or diagnosis. The phrase 'sharp, stabbing pain' is a direct quote from the patient.
Why the other options are wrong
- A. This contains an interpretation ('likely musculoskeletal') which is not appropriate for a medical assistant to document as a diagnosis.
- C. This is an observation, but 'appears to be in significant pain' is subjective interpretation rather than a direct quote or measurable observation.
- D. This includes a diagnosis ('probably disc-related'), which is outside the medical assistant's scope of practice.
Documentation Accuracy
The principle of recording complete, factual, and unbiased information in a patient's medical record.
- Record objective observations and patient's subjective statements.
- Avoid personal opinions, interpretations, or diagnoses.
- Ensure clarity and legibility.
Memory trick: Record Exactly What You See and Hear.