Medical Assistant Terms & Vocabulary

Aseptic technique

Practices that prevent contamination by microorganisms during procedures.

Chief complaint (CC)

The main reason the patient is being seen, recorded in the patient’s own words when possible.

CPT code

A five-digit code that describes a medical service or procedure for billing.

EHR

Electronic health record: the digital chart that stores a patient’s history, medications, notes and results.

HIPAA

Federal law that protects the privacy and security of patients’ health information.

Intramuscular (IM) injection

A shot delivered into muscle, commonly the deltoid or vastus lateralis.

Point-of-care testing (POCT)

Simple lab tests done in the clinic, such as glucose, rapid strep or urine dipstick.

Prior authorization

Approval an insurer requires before it will cover certain services or medications.

Rooming

Bringing a patient from the waiting area to an exam room and preparing them for the provider.

Standard precautions

Infection-control practices used with every patient, such as hand hygiene and gloves.

Subcutaneous (SubQ) injection

A shot delivered into the fatty tissue just under the skin.

Triage

Sorting patients by urgency so the most serious needs are handled first.

Two patient identifiers

Two pieces of information, usually full name and date of birth, used to confirm identity before any procedure.

Venipuncture

Puncturing a vein to collect blood.

Vital signs

Core measurements of body function: temperature, pulse, respirations and blood pressure, often plus oxygen saturation and pain level.

Practice these terms

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