Documentation is crucial in the healthcare setting. The MA must learn how to properly document in a patient’s file. Below you will find six patient scenarios that require you to chart in a patient’s file and provide telephone triage documentation.

HINT: When reading the scenario, highlight the information that will be needed for your documentation. Be sure to include the patient’s name, allergies, and date/time. If the date and time is not provided then use today’s date and time for convenience. Use appropriate abbreviations when possible and make your documentation clear for other heathcare professionals to read clearly. Also, be sure to close out your documentation with a line —— and your Initials with your credentials. Please see example below in red:

6/19/20XX: CC: cut on R ring finger from kitchen knife. Pt was cutting chicken. Bleeding has not stopped. Placed finger in wrapped ice. BP: 130/82, W: 132. Current meds: Cannabis recreational on weekends, D3, Estrace 2mg ————————————————————– CH,CMA(AAMA)®