Medical assistants are responsible for documenting and maintaining patient health records. These records detail the evaluation, management, and treatment given to the patient. Patient records are critical to the patient's care. WIthout accurate and complete patient records, medical care can easily be compromised with the potential for (unintentional) harm to the patient.
Past health history
Past health history includes the patient's past illnesses such as childhood illnesses, accidents, hospitalizations, and operations. Because the patient is describing a past accident, it should be documented under the past health history section. The patient is not mentioning any signs and symptoms; therefore, this should not be included in the reason for seeking care section. The patient is not mentioning present health status; therefore, this should not be included in the history of present illness. The patient does not mention daily activities; therefore, this should not be included under the "functional assessment" section.
Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong, and then call on your knowledge, skills, and abilities to choose from the remaining responses.
Musculoskeletal system
The review of body systems records the past and present health status of each body system. In the musculoskeletal system, the problems associated with the muscles and the skeleton, such as muscle pain, cramps, gait problems, and back pain, are included. In the endocrine system, the symptoms and history of endocrine disorders such as diabetes and thyroid gland disorders are recorded. In the neurologic system, motor functions, cognitive functions, sensory functions, and mental status are included. In the peripheral vascular system, the symptoms associated with the obstruction of blood flow in the arteries and veins are included.
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