Elizabeth is a medical assistant in a physician's office. The next patient is a 35-year-old female who is very underweight. The patient becomes upset and refuses to allow Elizabeth to weigh her

Question

Once in the treatment room, the patient tells Elizabeth that she has come to the office today because she has not been feeling well. She states she is "just not hungry" and often feels lightheaded and dizzy. She states this has been going on for three months. She denies being on any current medications. How might Elizabeth document this information into the medical record? Discuss how professionalism relates to the medical record in this specific case.

What will be an ideal response?

Answer 1

ANSWER: Patient presents with c/o lightheadedness and dizziness x 3 months, stating, "I am just not hungry". Patient refused to be weighed. Patient denies any current medications."
Elizabeth needs to be sure she does not include any defaming remarks in the medical record. It would be unprofessional for Elizabeth to state that the patient is too thin, or too skinny , or to impart any possible diagnosis such as anorexia or bulimia in the medical record. It is outside the scope of practice for a medical assistant to make a diagnosis. The entry into a medical record should be concise and thorough.