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chief complaint

specific symptom or problem for which the patient is seeing the physician today.

review of systems

inquires about the system directly related to the problems identified in the history of the present illness.

source-oriented medical record

a type of patient chart record keeping that incldues seperate sections for different sources of patient information.

present illness

what the patient is feeling specifically

past medical history

includes all health problems, major illnesses, and surgeries that the patient has had.

family history

provides clues to the patient's present condition by asking open-ended questions about medical problems of siblings, parents, and grandparents. This will alert the physician to any hereditary and familial diseases and disorders.

social history

includes their marital status, sexual habits, occupation, hobbies, and use of alcohol, tobacco, and recreational drugs or other chemical substances.


symptom that is felt by the patient but not observed by others.


a patient sign that is visible, palpable, or measurable by an observer.



patient demographic data form


release of information

A statement that permits the provider to give the carrier information needed to help process the claim.

medical history form

commomly used to gather information from the patient before the visit

financial information form



providing factual support through written information.


the interchange of thoughts, opinions, or information by speech, writing, or signs.


acquired hypersensitivity to a substance.


protection of individuals or groups from a specific diseases by vaccination or the injection of immune globulins


determination of disease or condition.


the written and other recorded events of people


required for each medication, treatment/procedure, or medical assistant action; it accounts of the patient's condition and activities must be charted in a clear and meaningful way.


drugs that are administered to a patient who is sick or in pain


microorganisms cultivated in a nutrient medium.









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