medical assisting

skills rubric

third ring

when performing a telephone screening by when must you answer the phone?

office, name, “how may i help?”

what must you lead a call with after picking up the phone?

who the message is for; who you are; date and time; patient name, DOB, and age; callers name; reason for the call; call back number and best time to call; allergies; patient chart number; medication refill and instructions; pharmacy name and number; urgency

what information must you record on the HOSA office message form and make sure you obtain from the patient?

attach it to the message form

what must you do with the patient’s chart once you’ve documented the information on the office message form before sending it to the appropriate provider?

first

the patient should hang up…

prescription refill call

take a message with essential information about the medication. be sure to include the pharmacy name and number. attach request to the patient’s chart and place it in the physician’s message box

emergency call

quickly record the patient’s name and complaint and ask the patient to remain on the line and the 911 call initiated by office. stay on the line until 911 has been contacted. attach a note to the patient’s chart and place it in the physician’s message box.

insurance/billing calls

after confirming the identity of the patient, if the patient is entitled to the information, transfer the call to the insurance/billing coordinator. provide the phone number, extension, person’s name to whom they are being transferred in case of disconnection.

test results call

unless instructed to place call directly to provider, take a message with essential information about results being sought. attach request to the patient’s chart and place it in the physician’s message box

follow-up call

unless instructed to place call directly to provider, complete message form and attach to chart and place in the provider’s message box

physician call

determine the urgency of the call. if it is an emergency, ask the patient to hang up and call 911. if the provider is unavailable, attach request to the patient’s chart and place it in the provider’s message box.

verbalize

when signing on to computer using appropriate login and password you must…

full name, eye contact

when greeting the patient you must call them by their __________ while maintaining ______

insurance card

when receiving a new patient and creating an electronic record, what must you collect first after greeting the patient?

clipboard, pen, HOSA medical office registration form

after asking for their insurance card, you must give the patient ________ so they can complete it

simulated EHR

after scanning the insurance card, attach it to what and, using patient’s completed registration form, enter patient information into what?

HOSA medical office registration form

what is the simulated EHR represented as in the medical assisting practical

full name, preferred name, address, phone number, OK to leave detailed message on above phone, email, date of birth, last 4 digits of social security number, marital status, preferred language, race, ethnicity, religion, organ donor, new to practice, referred by, primary physician, emergency contact info, preferred method of communication, insured’s information

what information must be recorded in the simulated EHR?

subscriber name, birthdate, relation to patient, subscriber’s phone number, health plan name, health plan address, group number, subscriber number, eligibility date, co-pay

what insurance information must the medical assistant collect?

employer name, address, and phone number; patient occupation

what patient employer information must the medical assistant collect?

verbalize

the best way to ensure the judges know that the form has been properly signed and dated, as well as added to the patient chart, is by…

eligibility check

the insurance coverage can be verified by running an…

obtain and record a patient health history

skill III, can be performed with paper, pen, and clipboard or electronically

comfortable, private

where should the medical assistant escort the patient to before filling out their patient health history

1.5 - 4 feet

what distance should be maintained between medical assistant and patient during the interview

confidential

explain to the patient what the purpose of the health history is and that all the information obtained is…

patient health history

the purpose of a patient health history is to collect comprehensive information about a patient's medical background, which aids healthcare providers in diagnosing and treating medical conditions effectively.

name, date, DOB, age, date of last physical, and occupation

what is the first set of information that needs to be recorded in a patient history document

their chief complaint

along with the characteristics/reason for the patient’s visit, the medical assistant should also obtain what from the patient?

medications (dosage and reason for taking), allergies, symptoms

after the chief complaint has been recorded, record what information (in the appropriate order)

the HOSA medical office health history form

how do you ask all “symptoms” and “diseases and conditions” of the patient

hospitalization records

once all questions have been asked of the patient, request _____ _____ and surgeries

family history

what is the final section of the HOSA medical office health history form?

summarize

what should you do for the patient once you have finished writing/entering the information into the form

EMR/patient chart

with additional notes, the summary of the findings on the medical office health history form should be attached to the… and given to the provider

measure height and weight

skill IV, entirely physical

washed hands or used alcohol based hand rub

what is the first thing you must do before checking a patient’s height and weight?

greeted, identified patient, introduced self

upon the patient’s arrival, what is the first action the medical assistant should take

explain the skill

before proceeding with instructions, you should always _________ to the patient to avoid confusion or apprehension

remove shoes and heavy items in pockets

before the patient proceeds to the scale, the medical assistant must instruct them to…

place a paper towel on the scale

what should you do before the patient steps onto the scale

center

the patient should be assisted to stand where on the scale?

lower, upper

order you move the weight bars in

nearest ¼ pound

adding the upper and lower bar measurements, the patient’s weight should be measured to the…

documented

after both height and weight have been determined, the patient’s information should be ______ in the patient chart

wash hands a second time

before skill IV is officially completed, the medical assistant must…

prepare a routine physical exam

skill V, completely physical

asses the exam room, review patient’s chart

what are the first two steps involved in preparing/assisting with a routine physical exam?

wash hands (skill V 1)

before any equipment is touched, as directed in the scenario (to prepare it on the mayo tray or countertop) the medical assistant must…

towel

what do you cover the equipment with once it has been organized in order of use?

pull out step, gown and drape on table

after preparing the equipment but before calling the patient to the exam room, what should be done?

greet patient by name, introduce self and instructions, verbalize vital signs, height and weight, instruct patient to empty bladder, instruct to remove outer clothing, ensure patient ready

what steps (in what order) should be completed upon calling the patient to the exam room

horizontal recumbent

the patient should be positioned… once directed by the judge

horizontal recumbent position

head on a small pillow, arms flat at the sides, legs slightly apart, patient covered by drape (loose on sides)

instruct patient to dress

what should you do once the judge indicates the examination is complete?

provide instructions, ask for any questions, see them out

what should be done once the patient has dressed

put on gloves to wrap up table paper and dispose of disposable supplies in appropriate waste containers, disinfect surfaces, discard gloves, replace supplies, washed hands

what defines “properly cleaning the room” after helping with a routine physical exam

screen for visual acuity

skill VI

washed hands or used alcohol (skill VI)

before interacting with the patient to assess vision what should the medical assistant do?

glasses, contacts

must note if the patient is wearing either…

snellen chart instructions

patient is to read each line from the chart as it is pointed out using a pointer, and to keep both eyes open while covering one eye

20 feet

direct the patient to stand how many feet away from the chart?

both eyes

the patient must first read the chart with…

left eye

which eye is covered with the occluder first?

record the smallest line the patient could read with one or fewer mistakes

after the patient finishes reading with left eye…

right eye

after recording the vision of the left eye, repeat the same procedure covering the _____

squinting, turning the head

what individual accommodations might the patient attempt to make it easier to read the chart that the medical assistant should note?

jaeger chart

when done using the snellen chart, hand the patient the ______ to measure color vision

14-16 inches

the patient should hold the jeager chart how many inches away from the eyes?

read out loud

the medical assistant should instruct the patients to _____ the paragraphs they can read, first with corrective lenses, then without

clean supplies following agency policy and return them to proper storage

after recording the results on the patient’s chart and thanking the patient…

wash hands (skill VI second time)

before completing the skill VI procedure….

test urine with reagent strip

skill VII

assemble necessary equipment and supplies

what is the first step when testing urine with a reagent strip?

wash hands (VII)

what must be done by the medical assistant before they touch any specimen containers

laboratory report form

compare the name written on the specimen container to the name on what document?

gently rotating between hands

how does the medical assistant mix the urine specimen

clear end

how should you hold the reagent strip when immersing it in urine?

tap the edge lightly against container side

how do you remove excess urine from the reagent strip?

use a watch to time the intervals for each reagent

how do you determine when to read the reagent strip?

paper towel

where should you place the used strip after reading for judge verification?

discard them in biohazard receptacle

how should you dispose of the used strip and supplies?

follow agency protocol

how should the urine specimen be discarding after testing?

wipe the work area with surface disinfectant

what cleaning step is required after testing?

wash hands (skill VII time 2)

before recording the results for each section of the reagent strip in the patient chart, the medical assistant must…

sterile gloving

skill VIII

remove rings and watch

what is the first thing the medical assistant must do when attempting sterile gloving (even before washing hands for surgical asepsis!)

cuff toward you

how should the sterile glove package be opened?

grasp folded cuff (with non-dominant)

how should the first glove (dominant hand) be picked up?

keep its cuff folded back

when putting the first glove on, insert dominant hand while pulling the glove on with the other hand and

use gloved fingers under cuff

how should second glove be picked up?

insert non-dominant hand and ease glove on

how should the second glove be put on using gloved hand to pull the inside cuff?

thumb of gloved dominant hand

what should you avoid touching when putting on the second glove?

above waist level

where should your hands remain while wearing sterile gloves?

palm with your other hand and pull it off inside-out

how should the first glove be removed?

ungloved finger under the cuff and peel it off

how should second glove be removed?

biohazard

where should used gloves be discarded?

wash hands or use alcohol based rub (VIII time 2)

what is the final step after removing gloves?