CCMA - Clinical Patient Care - Section 3.2

Conduct patient intake including chief complaint documentation, medical and surgical history, and current medications.

Conduct patient intake by accurately recording the chief complaint, past medical and surgical history, family and social history, and current medications. Apply medication reconciliation principles to identify discrepancies before the provider encounter.

Patient intakeChief complaintMedical historyMedication reconciliation

Practice question for this objective

Free sampleClinical Patient Caremedium

While taking the history of a new 40 year old patient, the patient mentions that both their father and a brother had a heart attack before the age of 55. The medical assistant has already documented the past medical history and current medications. What is the BEST action for the medical assistant to take next?

ARecord the relatives' cardiac events under the patient's own past medical history because they relate to heart disease
BDocument the relatives, their conditions, and the ages of onset in the family history section of the intake record Correct
CDecide the patient is at high cardiac risk and add a note recommending early cardiac screening
DOmit the relatives' heart attacks because only the patient's own diagnoses are relevant to the intake record

Record a relative's illness, the relationship, and the age of onset in the family history section, keeping it distinct from the patient's own past medical history. Family history documents conditions in blood relatives along with the relationship and age of onset because patterns such as early-onset heart disease carry hereditary relevance; it is recorded separately from the patient's personal past medical history, and interpreting the resulting risk is the provider's role rather than the medical assistant's.

Why A is wrong: Grouping all cardiac details together seems efficient, but events affecting relatives belong in the family history; placing them in the patient's past medical history misstates the patient's personal conditions.

Why B is correct: Correct: family history captures the relationship, condition, and age of onset for affected relatives, which is the appropriate place to record this information and is relevant for the provider's assessment.

Why C is wrong: The early-onset pattern does suggest elevated risk, but assessing risk and recommending screening is a clinical judgement outside the medical assistant's scope; that decision belongs to the provider.

Why D is wrong: Keeping the record focused on the patient seems sensible, but family history of early heart disease is a recognised and relevant component of intake that the provider needs to see.

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