Study notes covering the terminology medical assistants use daily, grouped by workflow: intake, vitals, procedures, EHR documentation, and billing basics.
| Term / Abbreviation | Meaning |
|---|---|
| Chief complaint (CC) | The main reason the patient is seeking care, in their own words. |
| History of present illness (HPI) | A timeline of how the current problem started and evolved. |
| Past medical history (PMH) | Prior diagnoses, hospitalizations, and chronic conditions. |
| Past surgical history (PSH) | Prior surgeries with dates if known. |
| Allergies & ADRs | Drug allergies, environmental allergies, and adverse drug reactions. |
| Medication reconciliation | Verifying every drug a patient takes, including doses and frequency. |
| Demographics | Identifying information: name, DOB, contact, insurance, emergency contact. |
| Triage | Assessing patient acuity to prioritize who is seen first based on urgency. |
| Term / Abbreviation | Meaning |
|---|---|
| Blood pressure (BP) | Systolic over diastolic in mmHg — e.g., 120/80. |
| Heart rate (HR) / Pulse | Beats per minute. Normal adult resting: 60-100 bpm. |
| Respiratory rate (RR) | Breaths per minute. Normal adult: 12-20. |
| Temperature (T) | In °F or °C. Normal: ~98.6°F (37°C). Documented with route (oral, tympanic, temporal, axillary). |
| SpO2 (pulse oximetry) | Peripheral oxygen saturation as a percentage. Normal: ≥95%. |
| Weight & height (wt/ht) | Used to calculate BMI and dose medications. |
| Pain scale | Self-reported on a 0-10 scale (or pediatric/non-verbal scales). |
| Term / Abbreviation | Meaning |
|---|---|
| Phlebotomy | Drawing blood from a vein for laboratory testing. |
| Venipuncture | The act of puncturing a vein, typically for blood draw or IV access. |
| Capillary puncture | Finger or heel stick for small blood samples (e.g., glucose). |
| Electrocardiogram (ECG/EKG) | Recording the electrical activity of the heart with skin electrodes. |
| Spirometry | Pulmonary function test measuring how much and how fast a patient can exhale. |
| Nebulizer treatment | Inhaled medication delivered as a fine mist via mask or mouthpiece. |
| Wound care / dressing change | Cleaning, assessing, and re-dressing a wound under provider direction. |
| Sterile technique | A method of preventing contamination during procedures. |
| PPE (personal protective equipment) | Gloves, gown, mask, and eye protection worn to prevent exposure to infectious material. |
| Term / Abbreviation | Meaning |
|---|---|
| EHR / EMR | Electronic health record / electronic medical record — the digital chart. |
| SOAP note | Subjective, Objective, Assessment, Plan — a structured visit note. |
| Progress note | Documentation of a single visit or a change in patient status. |
| Order entry (CPOE) | Computerized provider order entry for labs, imaging, and medications. |
| Referral | A formal request for the patient to be evaluated by a specialist. |
| Authorization / pre-auth | Insurance approval required before certain services are performed. |
| Encounter | A single patient visit — what gets billed and documented. |
| Term / Abbreviation | Meaning |
|---|---|
| ICD-10 | Standard diagnosis code system used on every claim. |
| CPT | Procedure and service codes used for billing. |
| HCPCS | Codes for supplies, equipment, and non-physician services. |
| Copay | Fixed amount the patient pays at the time of service. |
| Deductible | Amount the patient pays before insurance starts covering services. |
| EOB | Explanation of Benefits — the insurer's summary of how a claim was processed. |
| HIPAA | Federal law protecting patient health information privacy and security. |
| Term / Abbreviation | Meaning |
|---|---|
| Hypertension | High blood pressure — frequently managed in primary care. |
| Hyperglycemia / Hypoglycemia | High / low blood glucose, monitored in diabetic patients. |
| Tachycardia / Bradycardia | Fast / slow heart rate. |
| Dyspnea | Difficult or labored breathing. |
| Edema | Swelling caused by fluid retention. |
| Erythema | Skin redness, often from inflammation or irritation. |
| Lesion | Any area of abnormal tissue, used broadly across body systems. |