TL;DR

Medical Records and Documentation: SOAP notes, progress notes, problem lists, and medication records following legal/regulatory standards.

By Valenke Exam Prep Team·Last updated 2026-06-02

Medical Records and Documentation

MEDICAL ASSISTANT

Definition

SOAP notes, progress notes, problem lists, and medication records following legal/regulatory standards.

Equipment & Tools

SOAP notes, progress notes, problem lists, and medication records following legal/regulatory standards. Medical records management and SOAP format tested on MA exam.

Clinical connection: Pulse technique involves Radial (most common), count 60 sec if irregular. Apical: left MCL, 5th ICS, count 60 sec. Pulse defi.

Practical Example

Clinical Procedure: Temperature measurement is relevant to medical records and documentation.

Technique: Oral (under tongue, lips closed, 3-5 min), tympanic (pull ear up and back for adults), temporal (across forehead)

Normal values: Oral: 97.8-99.1 F. Rectal: +1 F. Axillary: -1 F. Tympanic: close to core.

Common Errors

Medical assistants must avoid these errors related to medical records and documentation:

Hemolysis: redraw, often caused by vigorous mixing or small-gauge needle
Nerve injury: remove needle immediately if patient reports shooting pain
Hematoma: apply pressure immediately
Failing to verify patient identity using two identifiers before any procedure

Assessment Techniques

Pulse: Radial (most common), count 60 sec if irregular. Apical: left MCL, 5th ICS, count 60 sec. Pulse deficit: apical minus radial.. Normal: Normal adult: 60-100 bpm. Tachycardia over 100, bradycardia under 60.

Respirations: Count without patient awareness (keep fingers on wrist), observe chest rise, count 30 sec x 2 or 60 sec if irregular. Normal: Normal adult: 12-20/min. Tachypnea over 20, bradypnea under 12.

Related Procedures

Related clinical procedures include phlebotomy. Order of draw for vacuum tubes:

Gold/SST (serum separator)
Green (heparin for chemistry)
Red (no additive for serum)
Lavender (EDTA for hematology/CBC)
Light blue (sodium citrate for coagulation)

Preferred venipuncture site: Median cubital vein (first choice).

Why It Matters

Medical records management and SOAP format tested on MA exam.

Related Terms

HIPAA Medical Terminology

Practice This Topic

Practice ma admin records → MEDICAL ASSISTANT

Ready to practice for the MEDICAL ASSISTANT?

Adaptive practice powered by Item Response Theory targets your weak areas. Start with 3 free sessions.

Start free practice →

Frequently Asked Questions

What injection technique applies to medical records and documentation?▼

For medical records and documentation: Intramuscular: angle 90 degrees, sites: Vastus lateralis (thigh), Deltoid (upper arm), Ventrogluteal (preferred for adults), Dorsogluteal (avoided due to sciatic nerve risk). Max volume: Deltoid max 1mL, VG/VL max 3mL. Needle: 21-23G, 1-1.5 inch.

What medical terminology applies to medical records and documentation?▼

For medical records and documentation: Prefixes: hypo- (below/deficient), dys- (difficult/painful), a/an- (without). Suffixes: -itis (inflammation), -otomy (incision into), -penia (deficiency).

What coding system is used for medical records and documentation?▼

For medical records and documentation: ICD-10-CM: Diagnosis coding with alphanumeric codes, 3-7 characters, maintained by WHO/NCHS. Examples: J06.9: Upper respiratory infection; E11.65: Type 2 diabetes with hyperglycemia; S52.501A: Fracture of lower end of radius, initial encounter.