Medical Assistant Certification (CMA / RMA) Administrative Practice Management Syllabus

In a SOAP note, what belongs in the 'Subjective' section?

Information reported by the patient in their own words: chief complaint, symptoms, history of present illness, and how they feel. It cannot be measured by the MA.

In a SOAP note, what belongs in the 'Objective' section?

Measurable, observable data: vital signs, physical exam findings, lab and diagnostic test results - facts the provider can see, hear, or measure.

In a SOAP note, what do 'Assessment' and 'Plan' contain?

Assessment is the provider's diagnosis or impression based on subjective and objective data; Plan is the treatment course: medications, tests ordered, referrals, patient education, and follow-up.

What is the difference between 'POMR' and 'SOMR' charting formats?

POMR (Problem-Oriented Medical Record) organizes the chart by a numbered list of patient problems, each documented with SOAP notes. SOMR (Source-Oriented Medical Record) organizes information by department or source (lab, radiology, progress notes).

What is the correct procedure for documenting in a paper medical chart?

Use permanent black ink, write legibly, date and time each entry, document objectively and promptly, never leave blank lines, and sign with name and credentials. Document only facts, not opinions.

Compare alphabetic and numeric filing systems for medical records.

Alphabetic filing orders records by patient last name, then first name - simple but less private and harder to scale. Numeric filing assigns each patient a number - more private, expandable, and reduces misfiles, but requires a cross-reference index.

What is 'terminal digit filing' and why is it used?

Records are filed by reading the last group of digits in the record number first (then middle, then first groups). It distributes files evenly across the storage system and reduces filing congestion and errors in large facilities.

What is the difference between active, inactive, and closed (purged) patient records?

Active records belong to patients currently being seen; inactive records are for patients not seen recently (often moved to separate storage); closed/purged records are for patients who have died, moved, or terminated care and are retained per retention rules.

What are the five basic steps of the filing process?

Conditioning (remove clips, repair), Releasing (mark 'OK to file'), Indexing/Coding (decide where it goes), Sorting (arrange in order), and Storing/Filing (place in the correct location).

How long must medical records generally be retained, and what governs the time frame?

There is no single federal rule; retention is set by state law and is typically 7-10 years for adults after the last visit. For minors, records are kept until the age of majority plus the state statute (often several additional years). HIPAA requires certain documents be kept 6 years.

Under HIPAA, what is required before a medical practice may release a patient's protected health information for non-treatment purposes?

A signed, dated written authorization from the patient (or legal representative) specifying what information may be released, to whom, the purpose, and an expiration date. The patient may revoke it in writing.

Name three disclosures of PHI that are permitted WITHOUT patient authorization.

Treatment, payment, and health care operations (TPO); plus required public health reporting (communicable diseases, abuse), court orders/subpoenas, and worker's compensation as allowed by law.

What is the 'minimum necessary' standard in release of information?

A HIPAA rule requiring that only the least amount of protected health information needed to accomplish the intended purpose be used, disclosed, or requested - it does not apply to disclosures for treatment.

What is the correct way to make a correction (error) in a paper medical record?

Draw a single line through the error so it remains readable, write the correct information, then date, time, and initial the change. Never erase, use correction fluid, or black out an entry.

In an EHR, how are corrections and amendments handled differently from paper records?

EHRs keep an audit trail/version history; corrections are entered as a new dated/timed/authored entry or addendum while the original remains. The original is never deleted, preserving the legal record.

What is the difference between a 'correction' and an 'amendment' to a health record?

A correction fixes a clear error (typo, wrong value) close to the time of entry. An amendment adds new or clarifying information after the fact; under HIPAA, a patient may request an amendment, and the provider must respond and document agreement or denial.

What are the standard parts (components) of a professional business letter?

Letterhead/heading (date), inside address, salutation, body, complimentary closing, signature block, and notations (enclosures, copies). Reference line and subject line are optional additions.

Compare full block and modified block business letter formats.

In full block format, every line begins flush at the left margin. In modified block, the date, complimentary closing, and signature block begin at the center of the page while other elements remain left-aligned.

How does a memo differ from a business letter?

A memo is for internal communication and uses a heading block (To, From, Date, Subject) with no inside address, salutation, or complimentary closing. A business letter is typically external and uses full formal structure.

What is telephone triage in a medical office?

The process of screening and prioritizing patient phone calls by urgency to determine the appropriate action - emergency referral, same-day appointment, advice, or routine scheduling - usually guided by written protocols.

During a phone call, what should a medical assistant do if a caller describes a possible emergency (e.g., chest pain, difficulty breathing)?

Stay calm, instruct the caller to call 911 (or stay on the line and alert the provider per protocol), do not hang up first, and follow the office's emergency triage protocol. Never give a diagnosis.

List four elements of proper telephone etiquette in a medical office.

Answer promptly (within 2-3 rings) and identify the office and yourself, speak clearly and courteously, ask permission before placing on hold, and verify caller identity before discussing PHI. Document important calls.

What information should always be obtained when taking a phone message for a provider?

Caller's name and callback number, date and time of call, patient's name/DOB, reason for the call, the urgency, and the name/initials of the person taking the message.

What precautions apply to communicating with patients by email or patient portal messaging?

Use secure/encrypted systems, verify the recipient, obtain patient consent, avoid sensitive results in unsecured email, keep messages professional, and document the communication in the medical record per HIPAA.

What are common features of a patient portal?

Secure messaging with the office, viewing lab/test results, requesting prescription refills, scheduling/requesting appointments, viewing visit summaries, and making online bill payments - enhancing patient engagement and meeting interoperability goals.

What is the proper procedure for processing incoming mail in a medical office?

Sort by priority, open and date-stamp (per office policy), check for enclosures, sort by recipient/urgency, flag items needing provider attention, and never open mail marked 'personal/confidential' addressed to an individual.

What is the difference between 'certified mail' and 'registered mail' for outgoing correspondence?

Certified mail provides proof of mailing and delivery with a tracking number and signature; registered mail offers the most secure handling with insurance and a documented chain of custody, used for valuable or highly confidential items.

Distinguish computer hardware from a peripheral device.

Hardware is the physical computer system. A peripheral is an external device connected to the computer for input, output, or storage - such as a keyboard, mouse, scanner, printer, or external drive.

Give examples of input versus output peripheral devices.

Input devices send data to the computer (keyboard, mouse, scanner, microphone, signature pad). Output devices receive data from the computer (monitor, printer, speakers). A touchscreen functions as both.

What is the primary function of practice management software (PMS), and how does it relate to the EHR?

PMS handles the administrative/financial side - scheduling, registration, billing, claims, and reporting - while the EHR holds clinical data. Many systems integrate the two so demographic and billing data flow between them.

Explain the '3-2-1 rule' of data backup and why backups matter in a medical office.

Keep 3 copies of data, on 2 different media types, with 1 copy stored offsite (or in the cloud). Regular backups protect PHI from loss due to hardware failure, ransomware, or disaster, supporting HIPAA data integrity/availability requirements.

Name three basic data security measures required to protect electronic PHI.

Unique user logins with strong passwords, automatic screen locks/logoff, role-based access controls, data encryption, audit trails, antivirus/firewall protection, and regular backups. Never share passwords.

What are first-line troubleshooting steps when an office computer or peripheral malfunctions?

Check power and cable connections, restart the device, confirm it is the correct/online device, check for error messages and supplies (paper, ink), and consult the user manual. If unresolved, contact IT support and document the issue - do not attempt unauthorized repairs.

If a printer will not print in the medical office, what should the MA check first?

Verify it is powered on and connected, the correct printer is selected, there is paper and ink/toner, the print queue is not jammed or paused, and there are no error lights - then restart the printer or clear the queue before calling IT.