Medical Assistant Prep / Unit 2 MAS 047 review, 2 to 3 minutes
Describing Where It Hurts
The idea
This example is constructed for this course. It shows how directional terms turn a patient's gesture into words that the provider, and every later reader, can rely on.
In practice
A patient sits on the exam table holding his arm and tells the medical assistant that it hurts "here," pointing to his forearm a little below the elbow. The medical assistant starts with the patient's own words, because the chief complaint is recorded as the patient said it: "pain in my arm, here." She then notes where he pointed, using the terms she knows. The spot is on his left forearm, the patient's own left, and it lies toward the elbow, so it is proximal on the forearm. She does not reach for a term she is unsure of, and she writes nothing about what the pain might be. When the provider comes in, she relays the location as she recorded it, and the provider examines the arm. A week later, another staff member reads the note. Because the location was written in shared terms, that reader can picture the same spot, even though they never saw the patient point to it.
Where people slip
Two mistakes undo this kind of record. The first is reversing left and right by describing the side from where you stand rather than from the patient's own body. The second is adding a guess, such as "probably a strain," which turns an observation into a diagnosis you are not permitted to make. Record the location precisely in the patient's frame, keep the patient's own words beside it, and leave its meaning to the provider, who will examine the arm and decide.
Your place on the trail
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