Patient Intake Flashcards

Which document must a patient sign before a medical assistant can share their health information with a third-party insurance company for billing purposes?

Answer: Authorization for Release of Information or acknowledgment of the Notice of Privacy Practices

Under HIPAA, sharing PHI for payment requires that the patient has received and acknowledged the Notice of Privacy Practices, or an explicit authorization.

A patient is accompanied by a spouse who wants to be present during intake. The medical assistant should:

Answer: Ask the patient privately if they consent to the spouse being present before proceeding

The patient's privacy is paramount; the patient must consent before any non-clinical person is present during intake or exam.

The normal range for a fasting blood glucose reading in an adult is:

Answer: 70–99 mg/dL

A normal fasting blood glucose is 70–99 mg/dL; values of 100–125 indicate prediabetes and ≥126 indicate diabetes.

A pediatric patient is brought in by a grandmother who is not the legal guardian. The grandmother requests to authorize a non-emergent procedure. The medical assistant should:

Answer: Explain that only the legal guardian or parent can authorize non-emergent procedures and contact the parent

Informed consent for non-emergency procedures must be obtained from the legal guardian or parent, not a non-guardian relative.

During intake, the medical assistant measures an adult patient's temperature at 100.5°F via oral route. This indicates:

Answer: A low-grade fever requiring documentation and provider notification

Normal oral temperature is 97.8–99.1°F; 100.5°F is a low-grade fever and should be documented and communicated to the provider.

Which of the following is the correct order for obtaining a complete patient history during intake?

Answer: Chief complaint → history of present illness → past medical/surgical history → medications/allergies → family/social history

The standard intake sequence begins with the chief complaint and progresses through present illness, past history, medications, allergies, and family/social history.

A patient reports taking warfarin daily. During intake, the medical assistant should flag this information because:

Answer: Warfarin has significant drug interactions and requires INR monitoring that affects clinical decisions

Warfarin is a high-alert anticoagulant with many drug interactions and requires close INR monitoring, making it critical information for providers.