Infection control, Body organization, Basic medical documentation, vital signs

week 2

Occupational Safety and Health Administration (OSHA)

federal government agency (the Department of Labor) that oversees work safety regulations.

Hazard classification in chemical labels, safety data sheets (chemical localized on the premises), and the bloodborne pathogen standard

Centers for Disease Control (CDC)

provide vaccinations and adhere to guidelines. Federal agency under the Department of Health and Human Services.

Human Immunodeficiency Virus (HIV)

a virus that weakens the body’s immune system (transferred between blood, semen, or other body fluids)

Hepatitis B

type of HIV that attacks the liver

Cycle of infection

reservoir host > means of exit > means of transmission > means of entrance > susceptible host (cycles back around)

Portal of entrance

-any cavity lined with mucous membrane

-Break in the skin

(mouth, nose, eyes, anus, and/or vagina)

droplet

3-6ft

vector-borne

tick, dog, mosquito

fomites

objects that have been touched

Medical asepsis

cleaning technique, based on maintaining cleanliness a preventing the spread of microorganisms in the medical enviroment

Surgical asepsis - sterile

free from all organisms, including viruses, and to keep organisms from entering the body

Personal Protective Equipment (PPE)

gloves, gowns, mask, eye protection, face shields

1:10

the concentration of bleach to water solution for cleaning ( every part bleach needs 10 parts water)

Touch

is the most common means of transmitting pathogens

fingernail length

trim to ½ or 1.3 cm past tip of fingers (avoid nail polish and artificial nails)

Hand washing

start of shift

before and after eating, bathroom, smoking/vaping

where hands are visibly soild

Alcohol based hand disinfectant needs to be a minimum of ___

60% alcohol

Donning

putting on

hand washing > gown > mask > eyewear > gloves

Doffing

taking off

gloves > gown > eyewear > mask > handwashing

Bloodborne Pathogens Standard

laws that protect healthcare workers and patients on how to dispose of potentially infectious waste such as

-blood products, body fluids, and human tissue

-cultures

-vaccines

-supplies containing body fluid, and used sharps

-used gloves and other disposable supplies

Engineering Controls

OSHA mandated the use of engineering controls for handling used needles, lancets ( small, sharp needle used to prick the skin and obtain a small blood sample, e.g., blood sugar), and other sharps

rules for engineering controls

-never recap, reuse, or bend used needles

-dispose of used needles, lancets, and other sharps into a designated, OSHA approved puncture-proof, leak-proof sharps container

-keep the sharps container upright and do not fill past the designated line

-never reach into or empty a sharps container

Biohazard

biological or chemical substance that is dangerous to human beings and the environment

Biohazard bag

dispose of used strips, plastic blood tubes, gauze, and any other non-sharp items that are heavily contaminated with blood (thick plastic bags, usually red or orange, that display the biohazard symbol)

Exposure Control Plan

-provide training to all employees and document training

-provide PPE, follow universal precautions, put in place for engineering controls, log exposure incidents

-provide hepatitis B vaccine at no cost

-Needlestick Safety and Prevention Act

Needlestick Safety and Prevention Act

evaluation of engineered safety devices, detailed log of sharps injuries, and work practice controls

Anatomy

study of body structure

Physiology

study of the body function

order of body oranization

cell > tissues > organ > organ system

Cell membrane

outer layer

Cytoplasm

liquid containing the cell’s structures

Mitochondria

make energy (ATP) for the cell (the powerhouse)

Nucleus

holds the DNA

DNA

chemical name for the molecule that carries genetic instructions in all living thingsGene

Gene

a portion of the DNA that determines a body trait

Heredity

the transfer of genetic traits from parent to child

Epithelia Tissue

covers the body and most organs (protects against invading pathogens and toxins), secretes enzymes, absorbs nutrients

Nervous Tissue

located in the brain, spinal cord, and peripheral muscle (sends impulses or electrical messages to the nerve endings, muscles, and glands in the body)

Muscle Tissue

contracts and relaxes (helps with movement of the body)

Skeletal muscle

attached to skeleton (voluntary movement)

Smooth muscle

located in the walls of hollow organs, the walls of blood vessels, and the dermis of skin (involuntary movement)

Cardiac muscle

located in the wall of the heart (involuntary movement)

Connective Tissue

supports, protects, and gives structure to other tissues and organs in the body

-stores fat

-helps move nutrients and other substances between tissues and organs

-helps repair damaged tissue

-most abundant

Types of connective tissue

Cartilage (joints, muscle)

Adipose (fat)

Blood (red and white blood cells, platelets, and plasma)
asseous (bone) tissue

organ

structure formed by organization of two of more different tissue types

organ system

organs joined together to carry out united functions

Integumentary System

skin and accessory organs (body’s first defense, regulates temperature, excretion, sensation)

Skeletal System

bones and joints (gives body structure and stability, protect organs from injury)

Muscular System

muscles and connecting structure (responsible for movement)

Lymphatic System

it’s made up of a network of thin tubes called lymph vessels, which connect lots of glands throughout your body called lymph nodes, where a fluid called lymph travels through the system and filters), spleen ( prevents infections with help from white blood cells)

Respiratory System

lungs and airways (deliver oxygen and eliminate carbon dioxide)

Digestive System

mouth esophagus, stomach, and intestines (liver and pancreas, provides and deliver nutrients)

Nervous System

brain, spinal cord, nerves (controls all other body systems)

Endocrine System

glands that secrete hormones (pancreas, pituitary, adrenal, thyroid glands)

Exocrine glands

release hormones into ducts

Endocrine glands

release hormones into the bloodstream

Cardiovascular System

heart and blood vessels (pumps blood, provides necessary nutrients, eliminates waste)

Urinary System

kidneys and bladder (filters blood, removes waste)

Female and Male Reproductive System

ovaries, uterus, vagina, testes, penis

Anatomical position

body is standing up right, facing forward, arms at the side and palms facing forward

Superior

above

Inferior

below

Proximal

closer to attached

Distal

further from attached

Medial

middle of the body

Lateral

side of the body

Ventral

(anterior or frontal)

towards the front of the body

Dorsal

(posterior)

toward the back of the body

Segittal/Midsagittal

divides body into right and left sides (midline through the center of the body)

Transverse

divides body into top and bottom (superior and inferior)

Cranial

brain

Spinal

continuation of cranial into the spine

Thoracic

chest (lungs, heart, major vessels)

Abdominal

abdomen (liver, intestines, colon)

RUQ

right upper quadrant of abdomen (pain - gallbladder)

RLQ

right lower quadrant of abdomen (pain - appendix)

LUQ

left upper quadrant of abdomen (pain - spleen)

LLQ

left lower quadrant of abdomen (pain - constipation)

pelvic

bladder

Documentation

all medical care, evaluation, and instructions the physician gives to the patient (if it was not documented it didn’t happen)

Maintenance

verifying accuracy

Releasing

proper signatures and verification (medical records belong to the provider not the patient)

source Oriented Medical Records (SOMR)

information should be grouped (progress notes, laboratory, radiology, correspondence)

forms and progress notes are filed in reverse chronological order (newest on top)

SOAP

Arranged as

Subjective (chief complaint)

Objective (measurable data- vital signs, lab results, measurements)

Assessment (medical diagnosis)

Plan (treatment)

CHEDDAR

expands from SOAP

Chief complaint

History (social and physical)

Examination (including extent of body system examined)

Details documented

Drugs and dosage

Assessment of diagnostic process and diagnoses

Return visit information and/or referral

Noncompliant patient

patient who does not follow the medical advice he/she receives from their physician

PHI

Protected Health information

the right to:

-notice of privacy practices

-limit or request restriction

-confidential communications

-inspect and obtain a copy

-Request and amendment

-know if their information has been disclosed and why

wrong way to make corrections to medical document

scribble or white out any entry, than write the correct information, then initial and date

how to make corrections to medical document

use a single line to mark through the error

Write the correct information, then add your initial, date, and time

When adding subjective comments, judgments, opinions, or speculation

call attention to problems or observations by attaching a separate note to the chart

Release of records request

written consent form for patients to release records containing confidential PHI, which belongs to the patient (verbal consent is not valid), a general form that is not specific

Release of Information form (ROI)

patients specify what information is shared, with whom, and for how long

Mature minor

STI, birth control, drug or alcohol counseling (results cannot be discussed with parents without permission)

internal audits

-review of their ability to back up the charges sent to the health insurance carriers

-look for “failure to document”

-meet the required standards

external audit

-performed by government entities

-managed care organizations

-private insurance carriers to see id medical records documentation backs up billing

Examination process

-patient interview

-establish reson for appointment

-determine “chief complaint” (subjective)

Interviewing skills

practice active listening and be aware of nonverbal clues and body language

-asking both open and closed ended questions

-mirroring

-reflection ( allowing patients to evaluate situation and give their own opinion

-clarification

6 C’s of charting

Client’s words

clarity

completeness

concessions

chronological order

confidentiality

Health history form

past medical history, family history, social and occupational history

Vital signs

temperature, pulse, respirations, blood pressure, pain assessment