What does the MA NOT sign or initial as part of a patient's medical record?

• A. Diagnosis
• B. Vital signs
• C. Allergies
• D. Medications

Answer: (A)

The key idea is who is responsible for clinical judgments versus data collection. A medical assistant can collect and record objective data like vital signs, list known allergies, and document medications a patient is taking. These items reflect the patient’s current state or history and are entered to keep the chart accurate and up to date. The diagnosis, however, is a clinical judgment based on evaluation of symptoms, exam findings, and any test results. That conclusion is made and signed or initialed by a licensed clinician, not by the medical assistant. So, the diagnosis is not signed or initialed by the MA, while vitals, allergies, and medications are the kinds of information the MA documents.