Medical Assistant Prep / Unit 2 MAS 046 review, 2 to 3 minutes
Reading a Note Aloud
The idea
This example is constructed for this course. It shows a medical assistant decoding a provider's note, word by word, so she can prepare correctly for the next step.
In practice
The provider leaves a note in the record for an adult patient: "Tachycardia noted. Tenderness right lower quadrant. Possible hepatomegaly. Order electrocardiogram today. Follow up in GI clinic." The medical assistant reads it part by part. Tachycardia: tachy, fast, and cardia, heart, so a fast heart rate. Right lower quadrant: the patient's own lower right abdomen, not her right as she faces him. Hepatomegaly: hepat, liver, and megaly, enlargement, so an enlarged liver; the word "possible" shows that the provider has not decided. Electrocardiogram: the recording of the heart's electrical activity, which is the task assigned to her today. GI clinic: the gastrointestinal, or digestive system, clinic. With each term decoded, she knows that her immediate job is to prepare the patient and the equipment for the electrocardiogram. She also understands why the provider wants it, because of the fast heart rate already noted.
Where people slip
Decoding the words gave her the meaning of the note, not the right to discuss it. When the patient asks, "Is something wrong with my liver?", she answers that the provider will go over the findings with him, and she lets the provider know that the patient is worried. She does not repeat the word possible, does not guess what an enlarged liver could mean, and does not reassure him either way, because reassurance is also a judgment. Understanding the note let her do her own part well, and it left every explanation, and every reassurance, to the provider.
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