Certified Medical Assistant (CMA AAMA)Communication and Legal/EthicalEasy
A medical assistant is documenting a patient's vital signs. The patient's blood pressure is 138/86 mmHg, heart rate is 72 bpm, respiratory rate is 16 breaths/min, and temperature is 98.6°F (37°C). The medical assistant should document this information in which section of the patient's electronic health record?
- AObjective Data
- BPast Medical History
- CChief Complaint
- DReview of Systems
Show answer & explanationAnswer & explanation
Correct answer: A. Objective Data
Vital signs are measurable and observable facts about the patient's current physiological state. This type of information falls under objective data in the patient's electronic health record, as it can be directly measured and verified by the medical assistant.
Why the other options are wrong
- B. Past medical history includes previous diagnoses, surgeries, and significant health events.
- C. Chief complaint is the main reason for the patient's visit, stated in their own words.
- D. Review of systems is a systematic inquiry about the patient's body systems, reported by the patient.
Objective Data
Factual, measurable, and observable information gathered during a patient encounter.
- Includes vital signs (BP, HR, RR, Temp)
- Physical examination findings
- Laboratory and diagnostic test results
- Can be verified by other healthcare professionals
Memory trick: Objective data is what you Observe and measure, like vital signs on a chart.