In all the chapters the Case Studies represent situations similar to those that the medical assistant may encounter in daily practice. Students are encouraged to consider the case study as they read each chapter.

A man is waiting at the busy family practice door on Monday morning as Paul, the medical assistant, arrives to open the office. He instantly recognizes the man as Christopher Hansen, a patient of Dr. Jones's and the first scheduled patient of the day. Mr. Hansen states that he is very ill and needs to see a doctor as soon as possible. Paul assists Mr. Hansen to an examination room and picks up the patient chart from the rack that holds the charts for the day's patients.

As Paul begins to check the patient's vital signs, he asks Mr. Hansen what brings him to the doctor today. The patient grips his lower right side as he responds that his stomach hurts a lot. The patient also reports running a temperature between 100.5° and 101.3° for a full day and that he has not been able to eat in the last day because of his stomach pains. Paul knows that this information is important to chart in the permanent record as subjective information that has been stated by the patient.

Paul carefully writes downthe vital signs for inclusion in the patient chart. He continues his evaluation with an abdominal exam to identify the exact area of tenderness. Paul knows that this information is important to chart in the permanent record as objective information that has been observed by the medical professional.

Paul is charting information in the patient record using the SOAP charting method:

S for subjective

O for objective

A for assessment

P for plan

Paul notifies the physician that the patient is ready for his exam. Dr. Jones completes the record after he evaluates the patient and makes entries to the chart for assessment and the plan for care. The medical record reflects the good clinical management that the patient receives.

As you read this chapter, consider the following questions:

1. Why is an accurate medical record important to the care of a patient?

2. Why is interviewing the patient important to the medical evaluation?

3. What are the six Cs of charting and what do they mean to you as a medical assistant?

4. What are the differences between the conventional and the POMR system of keeping charts?

5. What are some helpful tips you might use as you perform transcription/