- Normal adult pulse
- 60–100 beats per minute.
- Normal adult respirations
- 12–20 breaths per minute.
- Normal adult temperature
- 97.8–99.1 °F (average ~98.6 °F).
- Normal adult blood pressure
- Under 120/80 mmHg.
- Normal pulse oximetry (SpO₂)
- 95–100%.
- IM injection angle
- 90° — into muscle (e.g., deltoid, ventrogluteal).
- SubQ injection angle
- 45° — into the fatty tissue beneath the skin.
- Intradermal (ID) injection angle
- 10–15° — a shallow angle into the dermis.
- BMI of 30 or higher
- Classified as obese.
- BMI 25–29.9
- Classified as overweight.
- BMI 18.5–24.9
- Classified as normal weight.
- Lavender (purple) tube additive
- EDTA — used for CBC and hematology.
- Light-blue tube additive
- Sodium citrate — used for coagulation (PT/INR, PTT).
- Red / gold (SST) tube additive
- Clot activator / gel — serum chemistry and serology.
- Green tube additive
- Heparin — plasma chemistry and STAT electrolytes.
- Gray tube additive
- Sodium fluoride — glucose and lactate testing.
- Order of draw
- Cultures, light blue, red/gold, green, lavender, gray.
- Most common venipuncture site
- The median cubital vein in the antecubital fossa.
- Rights of medication administration
- Right patient, drug, dose, route, time, and documentation.
- Two patient identifiers
- Full name and date of birth — verified before any procedure.
- Most important infection-control measure
- Hand hygiene.
- Chain of infection (six links)
- Agent, reservoir, portal of exit, transmission, portal of entry, susceptible host.
- Standard precautions
- Treat every patient's blood and body fluids as infectious.
- Medical asepsis
- Clean technique that reduces and contains microorganisms.
- Surgical asepsis
- Sterile technique that eliminates all microorganisms.
- Sterile field 1-inch border
- Treated as non-sterile (contaminated).
- Sharps disposal rule
- Never recap by hand; drop point-first into a puncture-proof container.
- OSHA Bloodborne Pathogens Standard
- Federal rule governing sharps safety, PPE, and exposure control.
- 12-lead EKG electrodes
- 10 electrodes (4 limb + 6 precordial) produce 12 views.
- P wave
- Represents atrial depolarization.
- QRS complex
- Represents ventricular depolarization.
- T wave
- Represents ventricular repolarization.
- V1 electrode position
- 4th intercostal space, right sternal border.
- EKG paper speed (standard)
- 25 mm/sec — one small box = 0.04 s, one large box = 0.20 s.
- Wandering baseline artifact
- Drifting EKG baseline, often from patient movement or breathing.
- 60-cycle interference
- Uniform fuzzy EKG artifact from nearby electrical equipment.
- CLIA-waived test
- A simple, low-risk lab test a medical assistant may perform.
- Common CLIA-waived tests
- Blood glucose, rapid strep, urinalysis dipstick, urine hCG, hemoglobin A1c.
- Hemoglobin A1c measures
- Average blood glucose over about three months.
- Hematocrit
- The percentage of red blood cells in whole blood.
- Word root
- The core meaning of a medical term (e.g., cardi = heart).
- Prefix
- A word part at the beginning that modifies meaning (e.g., brady- = slow).
- Suffix
- A word part at the end, often naming a condition or procedure (e.g., -itis).
- Combining vowel
- Usually 'o' — joins word parts to ease pronunciation.
- -itis
- Suffix meaning inflammation (e.g., arthritis).
- -ectomy
- Suffix meaning surgical removal (e.g., appendectomy).
- -emia
- Suffix meaning a blood condition (e.g., anemia).
- brady-
- Prefix meaning slow (e.g., bradycardia).
- tachy-
- Prefix meaning fast (e.g., tachycardia).
- hyper-
- Prefix meaning excessive or above normal.
- hypo-
- Prefix meaning deficient or below normal.
- PRN
- As needed (pro re nata).
- STAT
- Immediately / at once.
- NPO
- Nothing by mouth (nil per os).
- PO
- By mouth (per os).
- BID
- Twice a day.
- TID
- Three times a day.
- QID
- Four times a day.
- Sagittal plane
- Divides the body into right and left portions.
- Frontal (coronal) plane
- Divides the body into anterior (front) and posterior (back).
- Transverse plane
- Divides the body into superior (upper) and inferior (lower).
- Anatomical position
- Standing erect, facing forward, arms at sides, palms forward.
- Superior
- Toward the head (opposite: inferior).
- Anterior (ventral)
- Toward the front (opposite: posterior/dorsal).
- Medial
- Toward the midline (opposite: lateral).
- Proximal
- Toward the trunk or point of origin (opposite: distal).
- Supine position
- Lying flat on the back — used for abdominal exams.
- Fowler's position
- Semi-sitting (45–60°) — used for breathing or head/neck exams.
- Lithotomy position
- On the back with feet in stirrups — pelvic/gynecologic exams.
- Sims' position
- Left side with right knee flexed — rectal exams and enemas.
- Prone position
- Lying face down — back and spine exams.
- Knee-chest position
- Kneeling with chest down — sigmoidoscopy and rectal exams.
- Auscultation
- Listening to body sounds, usually with a stethoscope.
- Palpation
- Examining by touch (feeling).
- Percussion
- Tapping the body and listening to the resulting sounds.
- Inspection
- Examining the body by looking.
- Autoclave
- Sterilizes instruments with pressurized steam.
- Sterilization indicator
- Confirms an autoclave load reached sterilizing conditions.
- Midstream clean-catch urine
- Cleansed collection of the middle portion of the urine stream.
- 24-hour urine collection
- A timed specimen collecting all urine over a full day.
- Chain of custody (drug screen)
- Documented control of a specimen to ensure legal integrity.
- Capillary (dermal) puncture
- A fingerstick or heelstick to collect a small blood sample.
- Six classes of nutrients
- Carbohydrates, fats, proteins, vitamins, minerals, and water.
- Main energy nutrients
- Carbohydrates and fats.
- Z-track method
- An IM technique that seals irritating medication in the muscle.
- Dosage formula
- (Desired dose ÷ dose on hand) × quantity on hand.
- Metric conversion: 1 gram
- Equals 1000 milligrams.
- Metric conversion: 1 milligram
- Equals 1000 micrograms.
- Contraindication
- A reason a drug or procedure should NOT be used for a patient.
- VIS (Vaccine Information Statement)
- A CDC document given to patients before a vaccination.
- VAERS
- Vaccine Adverse Event Reporting System — for reporting reactions.
- Insulin shock
- Hypoglycemia (low blood sugar) — give fast-acting sugar if conscious.
- Diabetic ketoacidosis (DKA)
- Hyperglycemic emergency with ketones — needs urgent care.
- First aid for bleeding
- Apply firm, direct pressure to the wound.
- Spill kit
- Supplies used to safely clean a blood or body-fluid spill.
- SDS (Safety Data Sheet)
- Describes a chemical's hazards, handling, and first aid.
- Crash cart
- A mobile cart of emergency medications and equipment.
- Bacteria vs virus
- Bacteria are treated with antibiotics; viruses are not.
- Direct transmission
- Spread by direct contact between an infected and a susceptible host.
- Indirect transmission
- Spread through a contaminated object, surface, or vector.
- PPE (personal protective equipment)
- Gloves, gown, mask, and eye protection against exposure.
- Chief concern
- The main reason, in the patient's words, for the visit.
- SOAP note
- Subjective, Objective, Assessment, Plan — a documentation format.
- Open-ended question
- A question that invites a detailed, narrative answer.
- Correcting a charting error
- Single line through it, then initial and date — never erase.
- Medication-error reporting
- Document and report per facility policy immediately.
- Centrifuge
- Spins a specimen to separate components (e.g., serum from cells).
- Wet mount
- A slide prep (saline or KOH) examined under the microscope.
- Quality control (lab)
- Routine checks confirming test accuracy and reliability.
- Calibration
- Adjusting an instrument to a known standard for accuracy.
- Korotkoff sounds
- The tapping sounds heard when taking a manual blood pressure.
- Systolic pressure
- The top number — pressure when the heart contracts.
- Diastolic pressure
- The bottom number — pressure when the heart rests.
- Apical pulse site
- Heard at the apex of the heart, 5th intercostal space, midclavicular line.
- Radial pulse site
- Felt at the thumb side of the wrist.
- Carotid pulse site
- Felt at the side of the neck.
- Tachycardia
- A fast heart rate (over 100 bpm in an adult).
- Bradycardia
- A slow heart rate (under 60 bpm in an adult).
- BP cuff size rule
- The bladder should encircle about 80% of the arm circumference.
- Too-small BP cuff
- Produces a falsely HIGH reading.
- Febrile
- Having a fever (elevated body temperature).
- Pyrexia
- Another word for fever.
- Pediatric vital signs
- Pulse and respiratory rates are higher than adults' and fall with age.
- Growth chart
- Plots a child's measurements against age-based percentiles.
- CBC
- Complete blood count — RBCs, WBCs, hemoglobin, hematocrit, platelets.
- WBC differential
- The breakdown of white blood cell types.
- ESR
- Erythrocyte sedimentation rate — a nonspecific marker of inflammation.
- INR
- International Normalized Ratio — monitors warfarin/anticoagulation.
- Lipid profile
- Measures cholesterol and triglycerides.
- Glucose tolerance test
- Measures how the body handles a glucose load over time.
- Urinalysis components
- Physical, chemical (dipstick), and microscopic exam of urine.
- PPD / TB skin test
- An intradermal test read at 48–72 hours for tuberculosis exposure.
- Rapid Group A strep test
- A throat-swab test for streptococcal pharyngitis.
- hCG test
- Detects pregnancy in urine or blood.
- Spirometry
- A pulmonary function test measuring how much/fast air is exhaled.
- Snellen chart
- Measures distance visual acuity (e.g., 20/20).
- Audiometry
- Hearing testing using pure tones and speech recognition.
- Holter monitor
- A continuous portable EKG worn for 24–48 hours.
- Disinfection vs sterilization
- Disinfection kills most microbes; sterilization kills all.
- Sanitization
- Cleaning to remove debris and reduce microorganisms before disinfection.
- Biohazard symbol
- Marks containers for infectious or regulated medical waste.
- Regulated medical waste
- Blood, body fluids, sharps, and contaminated materials.
- Post-exposure protocol
- Steps after a needlestick: wash, report, and seek evaluation.
- Eyewash station
- Used to flush the eyes after a chemical or fluid splash.
- Body mechanics
- Using proper posture and lifting technique to prevent injury.
- Incident report
- Documents an unexpected event or safety variance.
- Surgical scrub
- A thorough hand and forearm wash before sterile procedures.
- Surgical asepsis use
- Setting up a sterile field, minor surgery, certain injections.
- Suture vs staple removal
- Removing closures once a wound has healed, per order.
- Cast care
- Keeping a cast clean and dry; watch for swelling or numbness.
- Eye irrigation direction
- Flush from the inner to the outer canthus.
- Specimen labeling
- Label at the patient's side with two identifiers and date/time.
- Specimen contamination
- Improper collection or handling that invalidates a result.
- Refrigeration (specimen)
- A common preservation method for certain specimens.
- Microscope use
- Examines cells and microorganisms (e.g., on a wet mount).
- Drug action / indication
- What a drug does and the condition it treats.
- Adverse drug reaction
- An unintended, harmful response to a medication.
- Generic vs brand name
- Generic is the chemical name; brand is the trademarked name.
- Drug storage
- Per label — some require refrigeration or light protection.
- Sublingual route
- Medication dissolved under the tongue.
- Transdermal route
- Medication absorbed through the skin via a patch.
- Inhalation route
- Medication breathed into the lungs (e.g., nebulizer, inhaler).
- Instillation route
- Drops placed into the eye, ear, or nose.
- Needle gauge
- The diameter of a needle — a higher number is a thinner needle.
- Deltoid site
- A common adult IM injection site in the upper arm.
- Ventrogluteal site
- A preferred IM site for larger volumes.
- Vastus lateralis site
- The preferred IM site for infants.
- Immunization schedule source
- The CDC publishes childhood and adult immunization schedules.
- Cell, tissue, organ
- The structural units of the body, from smallest to largest.
- Integumentary system
- Skin, hair, and nails — the body's protective barrier.
- Cardiovascular system
- The heart and vessels that circulate blood.
- Respiratory system
- The lungs and airways for gas exchange.
- Four abdominal quadrants
- RUQ, LUQ, RLQ, LLQ — used to locate findings.
- HIPAA
- Protects patients' protected health information (PHI).
- PHI
- Protected health information — identifiable health data kept private.
- Minimum necessary standard
- Limit PHI access and disclosure to only what a task requires.
- HITECH Act
- Strengthened HIPAA rules for electronic records and breach notice.
- Informed consent
- Documented voluntary agreement after the provider explains risks.
- Implied consent
- Consent inferred from actions or assumed in a true emergency.
- Who obtains informed consent?
- The provider — the medical assistant may witness the signature.
- Negligence
- Failing to provide the accepted standard of care, causing harm.
- Assault
- Threatening or attempting unwanted touch (creating fear).
- Battery
- Actual unauthorized or unwanted touching of a patient.
- Slander
- Spoken defamation of character.
- Libel
- Written defamation of character.
- Abandonment
- Ending the provider-patient relationship without proper notice.
- Respondeat superior
- Employer is liable for an employee's on-the-job negligence.
- Good Samaritan law
- Protects those who give reasonable emergency aid in good faith.
- Standard of care
- The level of care a reasonably prudent professional would provide.
- Subpoena duces tecum
- A legal order to produce documents or records.
- Deposition
- Sworn out-of-court testimony recorded for use in a case.
- Scope of practice
- Tasks an MA is trained, delegated, and legally allowed to do.
- An MA may NOT
- Diagnose, prescribe, or independently interpret results.
- Drug schedules
- DEA classifications I–V by abuse potential (e.g., II = high).
- Controlled substance
- A drug regulated under federal law due to abuse potential.
- Mandatory reporting
- Required reporting of abuse, communicable diseases, and certain wounds.
- Advance directive
- A document stating care wishes if a patient can't decide.
- Living will
- An advance directive specifying desired treatments.
- DNR order
- Do Not Resuscitate — no CPR if the heart or breathing stops.
- DNI order
- Do Not Intubate — no breathing tube placed.
- Durable power of attorney (health)
- Names a person to make medical decisions for a patient.
- PSDA
- Patient Self-Determination Act — informs patients of directive rights.
- GINA
- Genetic Information Nondiscrimination Act — protects genetic data.
- Authorization to release PHI
- Written patient permission to disclose records.
- Patients' Bill of Rights
- Outlines a patient's rights to care, privacy, and information.
- Therapeutic communication
- Techniques (open questions, reflection) that build trust.
- Active listening
- Full attention, no interrupting, and confirming understanding.
- Communication block
- Advice, false reassurance, or changing the subject.
- False reassurance
- A communication block — 'Don't worry, it's nothing.'
- Nonverbal communication
- Posture, tone, facial expression, eye contact, gestures.
- De-escalation
- Calming an upset patient to reduce tension safely.
- Empathy
- Understanding and sharing another person's feelings.
- ADAAA
- Americans with Disabilities Act Amendments Act — accessibility compliance.
- Interpreter use
- Required for non-English-speaking and some impaired patients.
- Patient navigator / advocate
- An MA role helping patients access and coordinate care.
- Sender-receiver-feedback
- The basic communication cycle with confirmation of meaning.
- Defense mechanism
- An unconscious coping behavior (e.g., denial, projection).
- Cultural competence
- Respecting and adapting to a patient's cultural beliefs.
- Service recovery
- Resolving a complaint to restore patient satisfaction.
- Telephone screening
- Gathering data and triaging calls by urgency.
- Ethics vs law
- Ethics are moral standards; law is enforceable rules.
- Encryption
- Encoding electronic PHI so only authorized users can read it.
- Continuity of care release
- Sharing records with another provider for ongoing treatment.
- Confidentiality
- Keeping patient information private — verbal and written.
- Bias / stereotype
- An unfair generalization the MA must recognize and avoid.
- Emancipated minor
- A minor legally able to consent to their own care.
- Reportable wounds of violence
- Gunshot, stab, and similar wounds must be reported.
- Privacy vs confidentiality
- Privacy is the patient's right; confidentiality is the duty to protect it.
- Breach of confidentiality
- Disclosing PHI without authorization or a care reason.
- Verbal vs written consent
- Verbal may suffice for minor care; invasive procedures need written.
- Patient's right to refuse
- A competent adult may refuse care; document the refusal.
- Mature minor
- A minor judged able to understand and consent to certain care.
- Tort
- A civil wrong causing harm, leading to legal liability.
- Intentional vs unintentional tort
- Intentional (assault/battery) vs negligence (unintentional).
- Malpractice
- Professional negligence by a health-care provider.
- Statute of limitations
- The time limit for filing a lawsuit.
- Express contract
- An agreement stated clearly in words (spoken or written).
- Implied contract
- An agreement shown by actions or circumstances.
- Termination of care
- Ending a provider-patient relationship with proper written notice.
- e-Prescribing
- Electronically sending a prescription to a pharmacy.
- Schedule II drug
- High abuse potential, accepted medical use (e.g., opioids).
- Reportable communicable disease
- Certain infections must be reported to public health.
- Vital statistics
- Records of births, deaths, and similar events.
- Ethical standards
- Professional codes guiding honest, respectful conduct.
- Conflict of interest
- A personal interest that could improperly influence duties.
- Firewall
- A security barrier protecting electronic health information.
- Activity log / audit trail
- A record of who accessed electronic PHI and when.
- Geriatric communication
- Speak clearly, allow time, and respect dignity with older adults.
- Pediatric communication
- Use simple words and involve the caregiver as appropriate.
- Health literacy
- A patient's ability to understand health information.
- Teach-back
- Asking a patient to restate instructions to confirm understanding.
- Personal boundaries
- Limits protecting against harassment and unwanted attention.
- Clarification
- A therapeutic technique confirming the meaning of a message.
- Reflection
- Restating a patient's feelings to show understanding.
- Plan of care communication
- Coordinating the care team and referrals around the patient.
- Identifying medical specialties
- Knowing which specialist treats which condition for referrals.
- Message protocols (phone)
- Standardized handling of patient phone messages.
- ICD-10-CM codes
- Describe the diagnosis — why care was given.
- CPT codes
- Describe the procedure or service — what was done.
- HCPCS Level II
- Codes for supplies, equipment, and services not in CPT.
- Medical necessity
- A procedure code must be supported by a diagnosis code.
- CPT modifier
- A two-character add-on that refines a CPT code's meaning.
- Upcoding
- Billing a higher-level code than documented — fraud.
- Downcoding
- Billing a lower-level code than documented.
- Unbundling
- Separately billing services that should be billed together — fraud.
- Medicare
- Federal insurance for people 65+ and certain disabilities.
- Medicare Advantage
- A private-plan alternative to Original Medicare (Part C).
- Medicaid
- State-administered, income-based coverage.
- SCHIP
- State Children's Health Insurance Program for low-income children.
- TRICARE / CHAMPVA
- Coverage for military members, retirees, and dependents.
- Workers' compensation
- Covers job-related injuries and illnesses.
- Managed care (HMO/PPO)
- Plans that control cost through networks and referrals.
- EOB (Explanation of Benefits)
- A statement to the patient explaining claim payment.
- Remittance advice
- A statement to the provider explaining claim payment.
- Eligibility verification
- Confirming a patient's active insurance coverage.
- Prior authorization
- Insurer approval required before certain services or drugs.
- Denial / appeal
- A rejected claim and the request to reconsider it.
- ABN (Advance Beneficiary Notice)
- Warns a Medicare patient they may owe for a service.
- Deductible
- The amount a patient pays before insurance begins to pay.
- Co-pay
- A fixed amount the patient pays at the time of service.
- Co-insurance
- A percentage of the cost the patient shares after the deductible.
- Accounts receivable (A/R)
- Money owed TO the practice.
- Accounts payable (A/P)
- Money the practice OWES to others.
- Aging of accounts
- Tracking how long balances have been unpaid (30/60/90 days).
- End-of-day reconciliation
- Balancing the day's charges, payments, and adjustments.
- Write-off / adjustment
- Removing an uncollectible or contractual amount from a balance.
- Itemized statement
- A bill listing each charge and payment in detail.
- Insurance fraud
- Intentional deception for unauthorized benefit (e.g., upcoding).
- Insurance abuse
- Practices inconsistent with sound billing, causing improper payment.
- Time-specified (stream) scheduling
- Each patient gets a set appointment time.
- Wave scheduling
- Several patients booked at the top of the hour, seen in order.
- Modified wave scheduling
- Patients booked at intervals within the hour.
- Cluster scheduling
- Grouping similar visit types together.
- Double-booking
- Two patients in one slot — used sparingly for urgent add-ons.
- Scheduling matrix
- Blocking off times when a provider is unavailable.
- No-show
- A patient who misses an appointment without canceling.
- Routine vs urgent visit
- Urgent needs are triaged ahead of routine appointments.
- New vs established patient
- Established patients have been seen within three years.
- Ancillary services
- Lab, X-ray, surgery, and outpatient services coordinated by the MA.
- Patient demographics
- Identifying data: name, DOB, address, insurance, contact.
- Identity theft protection
- Verifying ID and safeguarding patient information.
- EHR (electronic health record)
- The digital chart storing a patient's medical information.
- Patient portal
- A secure website where patients view records and message staff.
- History and physical (H&P)
- A report documenting the patient's history and exam.
- Discharge summary
- A report summarizing a hospital stay at discharge.
- Operative note
- A report documenting a surgical procedure.
- Progress note
- A clinic note documenting an ongoing course of care.
- Consultation report
- A specialist's findings sent back to the referring provider.
- Pre-visit planning
- Preparing the chart and records before the patient arrives.
- Coordinate facility/equipment
- Booking rooms, staff, and equipment for an appointment.
- Collection agency
- A third party used to recover seriously overdue patient balances.
- Diagnostic coding
- Using ICD-10-CM to report the patient's condition.
- Procedural coding
- Using CPT to report the service or procedure performed.
- Bundling
- Combining related services under a single code.
- Clean claim
- A complete, accurate claim that processes without rejection.
- Claim rejection
- A claim returned for errors before processing.
- Explanation of benefits vs RA
- EOB goes to the patient; remittance advice goes to the provider.
- Birthday rule
- Determines primary coverage for a child with two insured parents.
- Coordination of benefits
- Rules deciding which plan pays first when there are two.
- Capitation
- A fixed per-patient payment to a provider regardless of services.
- Fee-for-service
- Payment based on each service provided.
- Premium
- The regular amount paid to keep an insurance policy active.
- Self-pay
- A patient paying out of pocket without insurance.
- Credit balance
- An overpayment owed back to the patient or payer.
- Posting payments
- Recording received payments to patient accounts.
- Day sheet
- A daily record of charges, payments, and adjustments.
- Encounter form / superbill
- Lists services and codes for a single patient visit.
- Precertification
- Insurer approval obtained before a planned procedure.
- Formulary
- An insurer's approved list of covered medications.
- Beneficiary
- A person covered by an insurance plan.
- Subscriber / policyholder
- The person who holds the insurance policy.
- Established patient (3-year rule)
- Seen by the practice within the past three years.
- Open-hours scheduling
- Patients seen on a first-come, first-served basis.
- Cancellation policy
- Rules for rescheduling and handling missed appointments.
- Recall system
- Reminding patients of needed follow-up or preventive visits.
- Triage (scheduling)
- Prioritizing patients by the urgency of their needs.
- Patient registration
- Collecting demographics and insurance at check-in.
- Release of information
- Disclosing records only with proper authorization.
- Record retention
- Keeping medical records for the legally required period.
- Active vs inactive record
- Current patients vs those not seen recently.
- Problem-oriented record (POMR)
- A chart organized around the patient's problem list.
