CMA (AAMA) Certification Exam key terms

The duties and procedures a medical assistant is legally permitted to perform, as defined by state law and the employing provider's written policies. Working outside these limits can expose the assistant and the employer to legal liability.

The degree of skill, care, and judgment that a reasonably competent professional with similar training would use in the same circumstances; it is the benchmark for judging whether negligence occurred.

A patient's voluntary agreement to a procedure after being told its purpose, risks, benefits, and alternatives. It is usually documented in writing before the procedure begins.

Agreement that is inferred from a patient's actions rather than from a signed form, such as extending an arm for a blood draw or arriving for a scheduled appointment.

Individually identifiable health information created or received by a provider in any form that relates to a patient's past, present, or future care or payment for care.

A HIPAA principle requiring providers to use, disclose, or request only the amount of protected health information needed to accomplish the intended purpose.

A legal document in which a competent adult records preferences for future medical treatment, such as a living will or a healthcare proxy, to be followed when the patient cannot speak for themselves.

Failure to use the care that a reasonable person would use under similar circumstances. In health care, proving it requires a duty, a breach of that duty, causation, and damages.

A legal doctrine holding an employer responsible for the negligent acts of employees committed while they are acting within the scope of their employment.

Purposeful, patient-centered communication that builds trust and encourages the patient to share concerns, using open questions, reflection, and attention to nonverbal cues.

A patient's ability to obtain, process, and understand basic health information and services so they can make informed decisions and follow care instructions correctly.

A digital, shared record of a patient's health information that supports documentation, order entry, results review, and billing across multiple visits and care settings.

A structured progress note organized into four parts: Subjective (the patient's report), Objective (measurable findings), Assessment (the provider's impression), and Plan (the next steps).

A fixed dollar amount that an insurance plan requires the patient to pay at the time of service, separate from any deductible or coinsurance the plan also applies.

The amount a patient must pay out of pocket for covered services within a benefit period before the insurance plan begins paying its share of the cost.

The share of covered charges, expressed as a percentage, that the patient pays after the deductible is met, while the insurer pays the remaining percentage.

A statement from an insurance plan showing which services were billed, the allowed amount, what the plan paid, and what the patient may owe.

The patient's written authorization allowing an insurance plan to send reimbursement for covered services directly to the provider instead of to the patient.

The process used when a patient has more than one insurance plan to decide which plan pays first and how the secondary plan covers the remaining charges.

A standardized set of five-character codes maintained by the American Medical Association that describes medical services and procedures for claims and reimbursement.

The code set used on claims to report a patient's diagnoses and the reason for the visit, using alphanumeric codes of up to seven characters.

Reporting a more complex or higher-paying service than the one actually provided. It is a form of health care fraud and carries civil and criminal penalties.

A report that groups unpaid patient and insurance balances by how many days they have been outstanding, helping staff follow up on overdue claims and identify collection problems.

Infection control practices applied to every patient regardless of diagnosis, including hand hygiene, gloves, gowns, masks, and safe handling of sharps and body fluids.

The six linked elements required for an infection to spread: infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host. Breaking any link prevents transmission.

Practices that keep objects and areas free of all microorganisms, including spores. They are used for invasive procedures such as urinary catheter insertion, sterile dressing changes, and surgery.

Barriers such as gloves, gowns, masks, and eye protection worn to protect the medical assistant and the patient from contact with infectious agents and body fluids.

Equipment that sterilizes instruments with steam under pressure at high temperature. Items must be cleaned, wrapped or pouched, and monitored to confirm the cycle worked.

Collecting a blood specimen by inserting a needle into a vein, most commonly in the antecubital area of the arm, for laboratory testing or donation.

The inner surface of the elbow where the median cubital, cephalic, and basilic veins are located; it is the preferred site for routine venipuncture.

A constricting band applied a few inches above the puncture site to fill the veins and make them easier to enter. It should be released within about one minute.

The required sequence for filling blood collection tubes during a multi-tube draw, designed to prevent additive carryover from one tube that could distort laboratory results.

Injection of a small volume of medication just beneath the epidermis, usually at a 5- to 15-degree angle, creating a small wheal as in allergy or tuberculin testing.

Injection of medication deep into a muscle at a 90-degree angle, using sites such as the deltoid, vastus lateralis, or ventrogluteal, for drugs that need rapid or complete absorption.

A technique for intramuscular injection in which the skin is pulled aside before the needle is inserted and released after withdrawal, sealing the drug in the muscle and reducing irritation.

The checks performed before administering any medication: right patient, right medication, right dose, right route, right time, and right documentation.

Measurements of body temperature, pulse, respiration, blood pressure, and often oxygen saturation and pain that indicate how well the body's basic functions are working.

The sounds heard through the stethoscope as the blood pressure cuff deflates. The first sound marks systolic pressure and the last sound heard marks diastolic pressure.

A severe, life-threatening allergic reaction with airway swelling, difficulty breathing, and a dangerous drop in blood pressure; it requires immediate epinephrine and emergency medical care.