Week 3 MA 117 In Person Quiz

What is the most frequently used tool?

computer

Understanding what is crucial to protecting patient information and ensuring efficient workflow?

basic computer functions, security protocols, and HIPAA compliance

Other office equipment besides a computer?

fax machines, printers, scanners, shredders, and postage meters

types of computers in healthcare

desktop and laptop

system software

the operating system, such as Microsoft Windows or Linux

Application software

such as Microsoft Office (word, excel, powerpoint, etc)

software used in the medical office

word processing

database management

accounting & billing

appointment scheduling

electronic transactions

word processing

common computer application used in most (if not all) office settings

database management

stored patient records such as billing info, medical chart data, etc.

accounting & billing

keeping track of patient accounts, creating billing statements, preparing financial reports, etc.

appointment scheduling

extremely valuable in a healthcare setting as more than one user can have access to the schedule at a time

electronic transactions

accepting credit card transactions, electronically submitting insurance claims, etc.

electronic security measures

protecting confidential files:

• setting passwords: follow specific guidelines, don’t ever share your PW, change it every 60-90 days

• encryption software: encodes personal information in such a way that only the intended party can “decode” it

• monitoring systems: monitors user activity to track and ensure there are no security breaches

preventing system contamination:

• antivirus software: regularly scans your computer system for viruses & sends alerts or automatically destroys it

• firewalls: a barrier to keep your computer protected from specific internet sites or potential computer hackers

disaster recovery plan:

• a plan in place to minimize equipment damage, retrieve important information, etc.

process to maintaining office supplies

how supplies are organized

creating a supply list

where the supplies are located

regular supply inventory

supply ordering schedule

administrative office supplies

clipboards, computer supplies (paper, ink, etc.), file folders, envelopes, HIPAA forms, patient questionnaires, insurance forms, patient education materials, pens, pencils, erasers, prescription pads, rubber bands, paper clips, stamps, stationary

clinical office supplies

alcohol pads, bandaging materials, patient gowns, culture tubes, gloves, needles, syringes, silver nitrate sticks, suture removal kits, table paper, urinalysis test strips, injectable medications, tongue depressors, hand sanitizer

inventory

the process of tracking supplies

includes: itemized inventory, inventory record, vendor list, current vendor catalogs, files for invoices, reorder reminder cards, ordering schedule, order forms for each vendor

steps to conduct a supply inventory

1. set aside regular uninterrupted time

2. gather supply list

3. have a blank itemized inventory sheet

4. count supplies

5. make note of supplies that need reordering (or if supplies will need to be ordered soon)

6. make plan of when and how much of each supply need to be ordered (create an ordering schedule)

7. order any vital supplies that are low right away

Things to consider to make sure you are HIPAA compliant

make sure your computer screens are not visible to patients or unauthorized personnel

ensure you log off or lock your computer when leaving your desk

never share your password with anyone

when restocking supplies

always check expiration dates

place new items behind older ones to ensure proper usage before expiration

expired medications and supplies should never be used on a patient

follow clinic protocols for properly disposing of expired supplies

label opened boxes with “OPEN” and the date to track usage

packing slips

packing slips are essential documents that accompany supply orders. When receiving and opening supply shipments, you must verify that all listed items are accounted for.

Packing slips also indicate if an item is “on backorder”, meaning it is temporarily out of stock and will be shipped when available.

receiving vaccine supply

most vaccines are shipped either refrigerated or frozen. Upon receiving a vaccine shipment, it is crucial to:

• open it immediately

• check the temperature indicator inside the package

• ensure the temperature is within the required range

• if the temperature is outside the acceptable range, report it to the clinical manager and label the shipment as “do not use”

• follow office protocols for returning compromised vaccines to the vendor

common in-office medications may include

testosterone and estrogen therapy drugs

antibiotics

pain medications

antihistamines

when receiving a medication shipment

verify storage requirements

check and document the expiration date before placing it into storage

ensure medications like vitamin B12 (cyanocobalamin) are stored properly, as they require protection from light exposure

responsibilities of working in reception

greeting patients

answering phone calls

providing directions

a positive first impression starts with

effective communication

professionalism

welcoming demeanor

first impression guidelines

maintain good personal hygiene and grooming

avoid perfumed lotions and perfumes

keep hair clean and tied back

ensure fingernails are clean, with no chipped polish and no artificial nails

maintain good oral hygiene

follow the office dress code (no tight clothing, short skirts, or open-toed shoes)

display a positive attitude and professionalism

use courtesy and diplomacy when interacting with patients and staff

practice empathy and show interest and concern for all patients

demonstrate positive interactions with colleagues

examples of facility accommodations

handicapped parking spaces

wheelchair ramps and accessible doors

wider hallways and accessible bathrooms

handrails for patient support

braille signage for visually impaired patients

large-print patient forms for those with visual impairments

common patient needs

patients using wheelchairs, walkers, or canes

individuals who are legally blind, deaf, mute

patients with prosthetics or missing limbs

individuals with limited mobility or developmental delays

patients with sensory disorders

patients with service animals or guide dogs

possible accommodations for patient needs

providing wheelchairs at all entrances and assisting patients who have difficulty moving

offering to guide visually impaired patients and allowing them to hold your arm if needed

reading documents to patients who have difficulty reading

providing interpretation services for patients who are deaf or hard of hearing

ensuring proper lighting and addressing flickering lights promptly

keeping background noise at a minimum and creating a calm environment

contagious patients

often have a designated separate waiting area

should be asked to wear a mask and roomed immediately

be mindful of high-touch surfaces and disinfect frequently

regularly clean and disinfect waiting rooms and reception areas to maintain a safe environment

safety plans

these plans outline protocols for injury prevention, handling hazardous materials, and responding to emergencies

OSHA hazard communication standard

requires employers to inform employees about hazardous chemicals they may come into contact with in the workplace. Typically done through Safety Data Sheets (SDS) that provide information on:

• chemical identification

• potential hazards

• first-aid measures

• safe handling and storage

• emergency response instructions

SDS

safety data sheets

electrical safety guidelines

avoiding the use of extension cords

addressing frayed electrical wires immediately

ensuring proper placement of electrical devices

using approved medical equipment in the clinic

fire safety guidelines

fire safety plans outline preventative measures and emergency response protocols, including:

• proper storage of flammable materials

• fire extinguisher maintenance and checks

• smoke detectors and alarm systems

• emergency fire evacuation plans

clinics must regularly inspect high-voltage equipment and electrical instruments to identify fire hazards before they become dangerous

chemical safety guidelines

safety data sheets (SDS) outline:

• hazardous chemicals used in the medical office

• proper handling and storage procedures

• first-aid response in case of exposure

Bloodborne Pathogens (BBP) and Personal Protective Equipment (PPE)

Medical assistants must follow strict protocols when handling bloodborne pathogens and always wear appropriate PPE when dealing with bodily fluids.

• Biohazard labels are used in areas dealing with infectious materials.

• Procedures should be in place for reporting needlestick injuries and handling BBP exposure incidents.

why are proper body mechanics and ergonomics important

Proper body mechanics and ergonomics are essential for medical assistants to prevent workplace injuries and ensure long-term health.

Body Mechanics

• Maintain proper posture with feet shoulder-width apart and knees slightly bent.

• Avoid twisting movements that strain the spine.

• Use proper lifting techniques (bend at the knees, not the back).

• Utilize assistive equipment such as lift aids when necessary.

Ergonomics

• Adjust workstations to fit your height and body type.

• Avoid excessive reaching, bending, or twisting.

• Take regular breaks to prevent stiffness and fatigue.

• Use ergonomic chairs, keyboards, and mouse pads to reduce strain.

EAP

emergency action plan

Emergency Preparedness Steps

• Designate responsible staff members to oversee evacuations and emergency response.

• Post evacuation routes throughout the clinic.

• Establish a clear evacuation procedure that includes special considerations for patients with disabilities. Clinic should be prepared for special patient needs (i.e. wheelchairs that can safely travel down stairs) and various zones outside of the building to ensure everyone is accounted for.

• Conduct regular emergency drills to ensure staff readiness.

• Maintain up-to-date emergency contact information for local authorities and emergency services.

proper documentation

Documentation in medical records tells a complete and clear story of a patient’s healthcare journey. Every encounter, diagnosis, prescription, referral, and test must be documented accurately to provide a comprehensive view of the patient’s history and treatment plan.

medical records overview

• Demographic Information

  • Name, date of birth (DOB), address, phone number, emergency contact, and insurance information.

• Health History (Hx)

  • Diagnoses, past medical conditions, previous procedures, and surgeries.

• Family History

  • Diagnoses of close family members, causes of death, and genetic conditions.

• Progress Notes

  • Current condition, treatment plan, and any follow-up care instructions.

• Procedures

  • Services performed, treatments given, and any follow-up care required.

• Diagnostic & Laboratory Testing

  • X-rays, ultrasounds, blood tests, and other lab results.

Source-Oriented Medical Records (SOMR)

SOMR is considered the traditional or conventional method of organizing patient information within the medical record, Source-Orientated Medical Records are organized by filing information in the medical chart by "source" - or where the category of information.

For example: Blood work from a laboratory would be filed under "Labs" while X-rays or CT scans would be filed under "Diagnostic Imaging". 

SOMR is still used in paper-based medical records. 

SOAP Documentation

SOAP is a structured format used to document patient encounters:

• Subjective (S) – The patient’s own description of their symptoms or concerns.

  • Example: "Patient complains of a sore throat for three days with no fever."

• Objective (O) – Information collected through tests and examination.

  • Example: Provider examines the patient and orders a strep test.

• Assessment (A) – The provider’s diagnosis.

  • Example: Strep test positive, diagnosed as "streptococcal pharyngitis" (ICD-10 code: J02.0).

• Plan (P) – The treatment plan, including medications, education, additional tests, and follow-up recommendations.

  • Example: "Treatment with Amoxicillin 500mg twice daily for 10 days."

The Six C’s of Documentation and Charting

1. Client’s Words – Use the patient’s exact words whenever possible. Do not rephrase or interpret their statements.

2. Clarity – Use clear sentences and proper grammar to avoid misinterpretation.

3. Completeness – Ensure that all forms and sections in the medical record are fully completed.

4. Conciseness – Be brief and to the point. Use accepted medical abbreviations where appropriate.

5. Chronological Order – Document all interactions in the order they occurred. Most Electronic Medical Records (EMR) automatically time-stamp entries.

6. Confidentiality – Ensure that all information remains protected and secure.

Timeliness

• Medical records must be up to date and readily available for providers.

• Delayed documentation can result in patient safety risks.

• Document all patient interactions as soon as possible or in real-time.

Accuracy

• Information recorded in the medical record must be precise and error-free.

• If unsure about a vital sign reading or medication spelling, double-check before recording it.

• When in doubt, ask the provider for clarification.

Medical Record Compliance and Legal Considerations

• Patients may not be denied a copy of their medical record due to overdue or outstanding bills (Federal Law).

• Patients have the right to request amendments or corrections to their medical record (Federal Law).

• The physician or facility that creates the record legally owns the medical record.

• The patient legally owns the medical information within the record.

• Retention Requirements:

  • Medical records must be kept for at least 10 years.

  • X-rays must be kept for at least 7 years.