HOSA Medical Assisting Ver 2

Role of a medical assistant

•Intervieiwing pateint

•Documenting pateint information

•Preparing the exam room before visit

•Positioning and draping patient

•Assisting the physician

•Cleaning room after visit

•Insteument care

•Maintaining supplies

•Confidentialtiy, infection control standards

Patient History:

Intake or Registration Form:

Demographic Info (DOB, racial or ethnic bg, education, social security number, nearest relative, name , address, sex

Patient History: Medical History

Chief complaint, present illness, past medical history, family history FH

Social history SH

Personal history PH

Patient History:

Test Results

Requested by physician

Performed in medical office

Ex) blood, urine test

Patient History:

Records from other physicians or facilities

Received with patients written permission

Patient History:

Diagnosis and detailed treatment plan

Determined by the physicians

Patient History:

Operative reports

On all procedures and surgeries

Includes treatment and follow up care info

Patient History:

Informed Consent forms

Signed by patient and indicates understanding of and grants permission for special treatments regardless of outcome

Patient History:

Hospital discharge summary

If patient was hospitalized includes info about stay reason for admission

Procedures

Treatment

Care plans

Medication

Patient History:

Correspondence

Written information stamped with the date in office

Equipment:

Ophthalmoscope

Used to examine eyes, shines light into eyes to check for abnormalities

Equipment:

Otoscope

Used to examine ears, light is focused through a disposable speculum (instrument used to view a body cavity)

Equipment:

Reflex hammer and pinwheel (sharp points)

Used to check knee reflexes

Used to check sensory perception

Equipment: Sphygmomanometer

Blood pressure cuff

Equipment:

Tuning Fork

Two pronged instrument used to vibrate at frequencies

Checks patients hearing

Equipment:

Laryngeal Mirror

Used to check larynx

Equipment:

Tape measure

Used to measure body parts

Ex) head, chest

Inspection

Visual examination of patients exterior appearance

Ex) seeing a rash, overall demeanor

Auscultation

Listening to sounds that are found within body

Ear against body of patient or use of stethoscope

Mensuration

Measuring body or parts of the body

Ex) patients height

Goniometer

used to measure joint flexibility

Mensuration

Palpitation

Touching

Light (checking outside of body, physical contact)

Deep ( pushing on the patients body

Ex) feeling a bump)

Percussion

Tapping areas of the body

(Many places should be hollow)

Manipulation

Moving the patients body parts

(Should begin from less intrusive to more intrusive)

Assisting in physical exam

•position and drape patient

•hand instruments, equipment to physician

•Document and label specimen

•provide reassurance to patient

•act as witness to patient physician interaction

•Carry out treatment plan

Preparing patient for exam

•obtain medical history

•acquire chief complaint

•measure vital signs

•put info into patients chart

Preparing for Exam

•Request patient to empty bladder prior to undressing for urine test

•Clear instructions on disrobing

•Look for sings of anxiety in patient

•gives sheets or drapes for patient

Temp in room should range from 71-73 degrees

Supine or horizontal recumbent

Patient lies on their back

Standard

Used for patients who can't sit upright or have back issues

Physician can exam full body

Dorsal Recumbent

Patient lies on back with knees bent upward

Relieves stress on lower back and abdomen

Used for vaginal and pelvic exams

Lithotomy

Patient is on back but legs are suspended in stirrups

Knees and hips and bent

Used in gynecologist office

Impossible for patients with bad knees

Can be used with paralyzed patient

Fowler's Position

Back straight, legs out, 90 degree angle

Used for head, neck chest exam

For patients who can sit upright

Semi Fowler's

Back is at 45 degree angle, legs out

For patients who can't sit upright

Takes stress off the back

Prone

Patient lies on stomach, head at side

For patients who are paralyzed, uncomfortable for patients with breathing problems and large breasts

Physician can exam patients back

Sims

Patient lays on stomach with right hand and leg bent at an angle (can be used for left side)

Takes pressure off of back

Used in rectal exams or enemas

Knee chest

"Doggy style"

Patient is on knees and forearms

Used for rectal exams, sigmoidoscopy, childbirth

Trendelenburg

Feet is higher than head

Slanted exam table

Used for patient in shock

Jackknife

Proctologist position.

Patient lies prone, table is then moved into a mountain shape

Used for rectal exams

Sitting position

Standard position

For people who can sit upright

Fenestrated drape

Drake that has a hole to expose certain body part for exam or surgery

A.D.A

American w/ Disabilities Act

•width of doorways and halls must accompany disabled

•placement of door handles

•grab bars

Six Cs of Charting

•CLIENTS own words in quotes

•CLARITY when recording info

•COMPLETENESS is essential

•CONCISENESS saves time and space •

CHRONOLOGICAL order of info

•CONFIDENTIALITY is mandatory

Height and Weight

(anthropometric)

One foot=12 inches=2.45 centimeters

One kilo is equal to 2.2 pounds

Common Lab and Diagnostic Procedures

CBC

Complete blood count

SMAC

Kidney and liver function (proteins, electrolytes, glucose)

ESR

Erythrocyte Sedimentation Rate

indicates inflammation in the body based on the number of red and white blood cells present

P.O.M.R.

Problem oriented medial record

One page dedicated to problems

Date is written next to problem and if issue was solved

S.O.M.R.

Source oriented medical record

Chronological order of visits

Latest visit first

Difficult to analyze pattern of symptoms.

S.O.A.P. Note

Ask patient what they came in for

SUBJECTIVE symptoms (can't be measured e.g. pain)

OBJECTIVE signs (things you see or can be measured)

ASSESSMENT ask questions to narrow down diagnosis

PLAN treatment

Lab or diagnosis tests that will be conducted e.g. blood work

Serum Albumin Test

Measures amount of Albumin in the blood, indicative of liver function

Albumin

A common protein in the blood produced by the liver. Maintains oncotic pressure, transports hormones, fatty acids, and many drugs. Competitively binds Ca+ ions.

Prevents photodegradation of folic acid.

Typical Serum Albumin

3.5-5 g/dl

Low Serum Albumin Level

Indicative of liver disease, inflammation, shock, malnutrition, nephritic syndrome, Crohn's disease, and Celiac disease, burns

High Serum Albumin Level

abrupt dehydration (treated with zinc and water)

Serum Transferrin Level (Total Iron Binding Capacity)

Measures amount of protein transferrin in the blood, a glycoprotein made by the liver that controls the level and distribution of free Iron in the blood.

High transferrin level

Indicates an iron-deficiency anemia

Iron-Deficiency Anemia

An anemia where there is not enough iron to form hemoglobin, an essential component of RBC's

Typical Transferrin level

170-370 mg/dl

Low transferrin level

indicative of poor nutrition

Blood Urea Nitrogen

Measures the amount of nitrogen in the blood originating from urea (protein breakdown), to find if the Kidneys are working properly

High BUN level

Heart failure, dehydration, high-protein diet, or Kidney problems

Low BUN level

Liver problems, 2nd/3rd trimester of pregnancy

Typical BUN level

6-20 mg/dl (1.8-7.1 mmol/L)

Creatinine excretion levels

Indicative of Kidney Function,

Typical Creatinine excretion levels

Males: 13-29 mg/kg of body weight/24 hours; Females: 9-26 mg/kg of body weight/24 hours

Low creatinine excretion levels

indicative of decreased glomerular filtration rate

High creatinine excretion levels

Hyper filtration, seen in diabetes patients and pregnancies. Also could be large protein intake

Serum Creatinine levels

Measures creatinine levels in the blood, indicative of renal function

Increased Serum Creatinine levels

indicative of a lower glomerular filtration rate, can also be large protein intake

Hemoglobin Level

Measures hemoglobin, a protein in the blood that carries oxygen and Co2

Typical Hemoglobin level

Male: 13.6-17.7 g/dl; Female: 12.1-15.1 g/dl. Lower for younger

Low Hemoglobin Level

Anemia. Nutritional Causes: B12 Deficiency, Folic acid deficiency, iron deficiency. Also blood loss, kidney damage, RBC synthesis problems, bone marrow suppression.

High Hemoglobin Level

Living at a high altitude, lung disease, tobacco smoking, bone marrow disorders, overdose of some drugs, blood doping

Hematocrit levels

Measures the percentage of the blood that is RBC's

Typical Hematocrit level

Males: 42-54%, Females: 38-46%

Low hematocrit level

Anemia. Nutritional Causes: B12 Deficiency, Folic acid deficiency, iron deficiency. Also blood loss, kidney damage, RBC synthesis problems, bone marrow suppression.

High hematocrit level

Dehydration, low availability of oxygen, genetic, erythrocytosis, COPD

RBC level

Measures amount of RBC's, similar to hematocrit testing

Normal RBC level

About 5 million cells/mcL

High RBC level

smoking, congenital heart disease, dehydration, kidney tumor, hypoxia, pulmonary fibrosis, or a bone marrow disease. Also high altitude, or with drugs like methyldopa or Gentamicin

Low RBC level

Anemia, bleeding, bone marrow failure, deficiency of erythropoietin (kidney disease), Leukemia, malnutrition, or deficiencies of copper, folic acid, B6, and B12 in the diet. Also drugs like chemotherapy drugs, chloramphenicol, hydrantoins, and quinidine.

HDL level

Measures high-density lipoproteins. "Good cholesterol"

LDL level

Measures low-density lipoproteins. "Bad cholesterol"

Optimum Total Cholesterol level

Optimum LDL level

Optimum HDL level

>60mg/dl protective against heart disease,

agar

a dried mucilaginous substance, or gelatin, extracted from algae, used as a culture medium.

bilirubin

a yellow breakdown product of normal heme catabolism. its levels are elevated in certain diseases, and it is responsible for the yellow color of bruises and the brown color of feces.

catheritization

to insert a catheter into a cavity (i.e. urinary bladder to remove urine) to remove body fluid.

chemical

a simple or compound substance used in chemical processes.

culture

a method of growing a microbial organism to determine what it is, its abundance in the sample being tested, or both. It is one of the primary diagnostic methods of microbiology.

exudate

pus; the collection of purulent material in a cavity.

glucose

a colorless or yellow, thick syrupy liquid obtained by the incomplete hydrolysis of a starch; a simple sugar.

Gram-negative

bacteria that takes on a pink color with Gram staining process.

Gram-positive

bacteria that takes on a purple color with Gram staining process.

guaiac

a solution to test for the presence of occult blood in the stool.

hematuria

blood in the urine.

hemolysis

dissolution; the breaking down of red blood cells.

human chorionic gonadotropin (hCG)

a hormone that is produced in pregnancy that is made by the embryo soon after conception.

in vivo

that which takes place inside an organism.

ketone (acetone)

products of metabolism generated from carbohydrates, fatty acids and amino acids in humans.

nitrite

a urine test that is positive in urinary tract infections from the presence of bacteria producing nitrates to nitrites.

physical

examination of the body; pertaining to the body.