Household measurements

15 drops (gtt) = 1mL

1 teaspoon (tsp) = 5ml

1 tablespoon (tbsp) = 15mL

1 fluid ounce (oz), 2 tbsp = 30mL

1 cup = 240mL

1 pint = 480 mL (about 500 mL)

1 quart = 960 mL (about 1 L)

1 gallon = 3,830 mL (about 1 gallon)

2.2 pounds (lb) = 1 kilogram (kg)

if 2.2 lb equals 1 kg, then the number of pounds to convert 66 lb equals how many (X) kg? Another way to accomplish this calculation is to divide the weight in pounds by 2.2 (because 1 kg = 2.2 lb).

Roots, prefixes, suffixes, and plurals

-Word roots are the core component of many words. Medical terms usually have one root but can have two or more

-A combining form is a word root with a combining vowel. Often, the combining vowel makes the medical term easier to pronoun

-Prefixes are word components that appear at the beginning of a word to change the meaning of the rest of the wor

-Suffixes are word components that appear at the end of the word to change the meaning of the rest of the word

Insurance Terminology

Advance beneficiary notice (ABN): A form provided to the patient when the provider believes Medicare will probably not pay for services received

Allowed amount: The maximum amount a third-party payer will pay for a particular procedure or service

Copayment: An amount of money that is paid at the time of medical serviceCoinsurance: A policy provision frequently found in medical insurance whereby the policyholder and the insurance company share the cost of covered losses in a specified ratio, such as 80:20

Deductible: A specific amount of money a patient must pay out of pocket before the insurance carrier begins paying

Explanation of benefits: A statement from the insurance carrier detailing what was paid, denied, or reduced in payment; also contains information about amounts applied to the deductible, coinsurance, and allowed amounts

Participating provider (PAR): Providers who agree to write off the difference between the amount charged by the provider and the approved fee established by the insurer

Types of insurance plans

Federal and state government plans include Medicare, Tricare, CHAMPVA, Medicaid, managed care plans, and workers’ compensation

Medicare generally covers patients age 65 and older by Part A (hospitalization) or Part B (routine medical office visits) benefits

Tricare authorizes dependents of military personnel to receive treatment from civilian providers at the expense of the federal government

CHAMPVA covers surviving spouses and dependent children of veterans who died as a result of service-related disabilities

Medicaid provides health insurance to the medically indigent population through a cost-sharing program between federal and state governments for those who meet specific eligibility criteria

Managed care is an umbrella term for plans that provide health care in return for preset scheduled payments and coordinated care through a defined network of providers and hospitals

Workers’ compensation protects wage earners against the loss of wages and the cost of medical care resulting from an occupational accident or disease as long as the employee is not proven negligent

private insurance plans include Blue Cross Blue Shield, Aetna, and United Healthcare. Blue Cross Blue Shield is America’s oldest and largest system of independent health insurance

Electronic submission of claims

Electronic claims can be submitted in several ways, such as direct billing or to a claims clearing house. Direct billing is the process by which an insurance carrier allows a provider to submit insurance claims directly to the carrier's electronic

Types of ancillary services

Urgent cares provide an alternative to the emergency department. They cost less, have a shorter wait time, and are often conveniently located. Most have flexible hours and offer walk-appointments

Laboratory services perform diagnostic testing on blood, body fluids, and other types of specimens to conclude a diagnosis for the provider

Diagnostic imaging machines such as x-ray equipment, ultrasound machines, magnetic resonance imaging (MRI), and computerized tomography (CT) take images of body parts to further diagnose a condition

Occupational therapy assists patients who have conditions that disable them developmentally, emotionally, mentally, or physically. Occupational therapy helps the patient compensate for the loss of functions and rebuild to a functional level

Physical therapy assists patients in regaining mobility and improving strength and range of motion, often impaired by an accident, injury, or as a result of a disease

Alternative therapies

Acupuncture involves pricking the skin or tissues with needles to relieve pain and treat various physical, mental, and emotional conditions.

Chiropractic medicine diagnoses and treats mechanical disorders of the musculoskeletal system, particularly the spine.

Energy therapy is the calm method of clearing cellular memory through the human energy field promoting health, balance, and relaxation. It is centered on the idea of a connection between the physical, emotional, and mental states of life found in various holistic healing techniques

Dietary supplements contain one or more dietary ingredients including vitamins, minerals, herbs, or other botanicals. A plant or part of a plant (flowers, leaves, bark, fruit, seeds, stems and roots, and amino acids) is used for its flavor, scent, or potential therapeutic properties.

SCOPE OF PRACTICE

Scope of practice describes the duties that can be delegated to medical assistants based on their education, training, and experience. The scope of practice for the medical assistant does not constitute the practice of medicine.

STANDARD OF CARE

Standard of care is the degree of care or competence expected in a particular circumstance or role. Standard of care applies to all health care professionals who provide care to patients. Providers are extensively trained skilled professionals who are licensed to diagnose conditions and treat patients. Medical assistants cannot diagnose, treat, or instruct patients to take any course of action.

brand/trade name. Assigned by the medication’s manufacturer, identifies the medication as the property of the company, begins with a capital letter

generic name. A noncommercial name for a medication is usually less complex than the medication’s chemical name and often more complex than a brand or trade name

calcium channel blocker. A medication that prevents the entry of calcium ions into the cells of the body, which can lower blood pressure and treat cardiac pain and dysfunction

antiplatelet. A medication that helps delay blood clotting. This medication differs from an anticoagulant because it affects arterial as well as venous blood

ACE inhibitor. An angiotensin-converting enzyme inhibitor, a type of antihypertensive (blood pressure lowering) medication

proton-pump inhibitor. A specific type of medication that reduces stomach acid

beta blocker. A medication that, by interfering with specific receptor sites in the heart, can help lower heart rate and blood pressure and treat many other cardiovascular disorders

leukotriene inhibitor. A specific type of medication that treats asthma by relaxing tight or constricted airways and inflammation in the airways

glucocorticoid. One of several hormones that have many functions, both naturally in the body and as a medication, including suppression of inflammation

ampule. A small, sealed, single-use glass or plastic container containing sterile parenteral medications or solutions

suppository. A small, solid, cylinder-shaped medication for insertion into the rectum or vagina; solid at room temperature, dissolves at body temperature

syrup. A concentrated solution of sugar in water with a flavoring, sometimes with medication in it

compound. Combination of atoms of an element; pharmacologically, it refers to a mixture of medications or medication with a specific base

extract. A concentrated combination of vegetable products and alcohol

potassium. A mineral that controls fluid volume, muscle and cardiac activity, and other bodily function

metered-dose inhaler. A medication-delivery device that disperses the medication as an aerosol spray, mist, or powder into the airways via inhalation

nebulizer. A device for creating and delivering an aerosol spray for inhalation

over-the-counter. Available for purchase without a prescription

suspension. A liquid preparation consisting of solid particles dispersed throughout a liquid in which they are not soluble

tincture. A medicinal preparation in an alcohol base, sometimes for oral and sometimes for topical us

MEDICATION SCHEDULE

Schedule I includes substances that have a high potential for abuse and no approved medical use in the United States. They are illegal, and providers may not prescribe them. These include heroin, mescaline, and lysergic acid diethylamide (LSD).

Schedule II includes substances that have a high potential for abuse, are considered dangerous, and can lead to psychological and physical dependence. These include morphine, methadone, oxycodone, hydromorphone, hydrocodone, fentanyl, and methamphetamine. Providers must give patients a handwritten prescription with no refills.

Schedule III includes substances that have a moderate to low potential for physical and psychological dependence. These include ketamine, anabolic steroids, and testosterone.

Schedule III includes substances that have a moderate to low potential for physical and psychological dependence. These include ketamine, anabolic steroids, and testosterone.

Schedule V includes substances that contain limited quantities of some narcotics, usually for antidiarrheal, antitussive, and analgesic purposes. These include diphenoxylate with atropine, pregabalin, lacosamide, and opium/kaolin/pectin/belladonna. Providers must sign prescriptions for these substances, and patients may refill them five times in 6 months.

WATER FUNCTIONS FOR THE BODY

The human body is 50% to 80% water. People can survive longer without food than they can without water—that is how essential it is

Drinking too little water can result in dehydration, which can adversely affect body temperature, heart rate, and mental and physical functioning. Without correction, dehydration can cause fatigue, weakness, dizziness, loss of balance, delirium, and exhaustion. Dehydration can also result from vomiting and diarrhea

Drinking too much fluid will not adversely affect healthy people; the body will eliminate it in urine. Excessive intake in infants, athletes, and people who have some medical conditions can cause hyponatremia if sodium losses are not replaced

PROTEIN IN THE HUMAN BODY

Proteins are large, complex molecules the body makes from amino acids, which are the natural compounds that plants and animal foods contain

Essential amino acids are ones the body cannot produce.

Nonessential amino acids are ones the body can make from essential amino acids or as proteins break down.

Conditional amino acids are not usually essential but might become essential when the body is undergoing stress or illness.

Carbohydrates are organic compounds that combine carbon, oxygen, and hydrogen into sugar molecules and come primarily from plant sources. Carbohydrates comprise the majority of the calories in most diets

Fats, or lipids, are a highly concentrated source of energy the body can use as a backup for available glucose

Unsaturated fatty acids are less dense and hea

Trans fat is a fatty acid used to preserve processed food products

Saturated fats are solid at room temperature

Fiber is a complex carbohydrate that humans cannot digest. There are many chemical names for various types of fiber, such as cellulose and pectin, but a common name for fiber is roughage

Vitamins are organic substances the body needs for various cellular functions. Each vitamin has a specific role. With the exception of vitamins D, A, and B3, the body cannot make them or cannot make enough of them, so they have to be part of dietary intake to promote health and avoid deficiencies

Fat-soluble vitamins: A, D, E, K

Water-soluble vitamins: B1, B2, B3, B6, folate, B12, pantothenic acid, biotin, c

Minerals are inorganic substances the body needs in small quantities for building and maintaining body structures. They are essential for life because they contribute to many crucial life functions, like those of the musculoskeletal, neurological, and hematological systems.

ROLES AND RESPONSIBILITIES

The role of a medical assistant is primarily to work alongside a provider in an outpatient or ambulatory setting, such as a medical office. Depending on the size of the facility, the medical assistant might be cross-trained to perform administrative and clinical duties. Administrative duties include greeting patients, handling correspondence, and answering telephones

Medical doctors (MDs) are considered allopathic providers and are the most widely recognized type of doctor. They diagnose illnesses, provide treatments, perform procedures such as surgical interventions, and write prescriptions

Osteopathic providers (DOs) complete requirements that are similar to those of MDs to graduate and practice medicine. In addition to using modern medicine and surgical procedures, DOs use osteopathic manipulative therapy (OMT) in treating their patients

Nurse practitioners provide basic patient care services, including diagnosing and prescribing medications for common illnesses. Nurse practitioners require advanced academic training beyond the registered nurse (RN) degree and have an extensive amount of clinical experience. Generally, nurse practitioners focus on preventive care and disease prevention.

Physician assistants practice medicine under the direction and supervision of a licensed MD or DO. Additionally, physician assistants are able to make clinical decisions and be responsible for a variety of services.

Medical laboratory technicians perform diagnostic testing on blood, bodily fluids, and other specimens under the supervision of a medical technologist.

Medical receptionists check patients in and out, answer phones, and perform filing, faxing, and other tasks.

Occupational therapists assist patients who have developed conditions that disable them developmentally, emotionally, mentally, or physically.

Pharmacy technicians assist pharmacists with duties that do not require the expertise or judgment of a licensed pharmacist.

Physical therapists assist patients in regaining their mobility and improving their strength and range of motion.

Radiology technicians use various types of imaging equipment to assist the provider in diagnosing and treating certain diseases.

COMMON PATHOGENS AND NON PATHOGENS

A bacterium is a single-cell microorganism that reproduces rapidly and causes many different infections.

A virus is a tiny micro-organism that causes many infections and diseases. Viruses require living tissue to survive and grow; so unlike bacteria, they are actually parasites

A fungus is a micro-organism that grows on or in animals and plants. The single-cell fungi are yeasts; multi-cell varieties are spore-producing molds. Most fungi do not normally cause diseases

A protozoon is a single-cell parasite that can be microscopic or large enough to see without a microscope. Protozoa thrive in damp environments and in bodies of standing water, such as ponds and lakes. They replicate rapidly inside a living host

Homeostasis is achieved when the body’s systems and biological processes maintain stability. The body has built-in regulatory processes that react to external environmental changes in order to sustain balance. The nervous system and endocrine system are primarily responsible for achieving and maintaining homeostasis, but all body systems play a role

GENERAL PT CARE

Computerized physician order entry (CPOE)

Providers can directly document orders into the EMR. This point-of-care documentation allows

for completion of the medical documentation at the time of the visit, assists in decreasing errors

associated with the legibility of writing, and ensures seamless communication between members of the health care team.

A medical assistant assists both the patient and the provider in regard to surgical interventions:

Preparing the surgical area and assisting the provider during the procedure

Providing education and support to the patient

planned surgical procedures commonly performed in a provider’s office include mole removals,

ingrown toenail removals, or wart removals. Unplanned surgical procedures include foreign body

removal or wound suturing

When setting up for the procedure, avoid contamination of the sterilized items or sterile field. When opening sterile packets or a Mayo stand cover, open the flaps away from you first and then open the closest flap. At least 1 inch around the sterile field is considered nonsterile

Checking the medication order the name of the medication, dosage, time, and route of administration directs the medical assistant in preparing the medication for administration.

Injection equipment and supplies correct syringes and needles for the route of administration and the medication are among the supplies to gather for injections. Alcohol swabs are necessary to wipe off vials or wrap around the neck of an ampule, as well as for skin preparation

NEEDLES AND GAUGES

The gauge describes the diameter of the lumen of the needle. The lower the gauge number, the wider the lumen. Gauges range from 14 to 31, with 14 beings the largest and 31 the smallest. The length indicates the distance from the hilt to the point of the needle. Needle lengths range from ⅜ to 4 inches.

Administration of medications

Choose the appropriate site based on the medication to be administered, the dosage, and the route

of administration. The routes of administration typically used in the parenteral administration of

medications are identified in the following charts. The dorsal gluteal site is no longer recommended

largely due to the potential complications that can occur if the sciatic nerve is damaged

VITAL SIGNS

Measuring temperature is actually determining the relationship between heat production and heat loss in the body, also referred to as metabolism. The most common cause of pyrexia, or fever, is infection. Fever is the body’s natural defense to fight invasive organisms and is therefore a normal reaction to illness

Heart rate is a reflection of pulse and is best palpated when an artery can be pushed against a

bone. The second and third fingers should be used to palpate the pulse. Pulse sites are chosen

based on the particular circumstances

Respirations are evaluated on rate, rhythm, and depth. The respiratory rate also decreases with age and is affected by health conditions or environmental factors. Respiratory rhythm is the breathing pattern, and depth describes how much air is inhaled.

Blood pressure is the single most important vital sign in identifying the force of the blood circulating through the arteries. Obtaining accurate blood pressure can significantly affect the patient’s treatment or additional diagnostic tests. Equipment used to manually determine blood pressure includes a sphygmomanometer

pulse oximetry is a valuable tool and a simple procedure to ascertain the percentage of oxygen saturation in the blood. Many pulse oximeters also display the heart rate.

asking the patient to rate pain on a scale of 1 to 10 (with 10 being the worst pain) is a means of assessing what the patient is experiencing

A staple removal device is used to remove staples. Remove every other suture or staple while observing the site. If at any time there is gaping, stop and notify the provider. Account for the total number of staples and sutures that were used to close the wound. When cutting sutures, cut close to the knot and pull the suture out with forceps by grabbing the knot and pulling, observing to ensure the entire suture was removed

ANTHROPOMETRIC MEASUREMENTS

height, weight, body max index, Pediatric measurements, Growth charts,

Considerations related to age, health status, and disability

OSHA also requires the disposal of infectious and hazardous waste to be handled according to safety standards.

OSHA guidelines for disposal of biohazardous materials and item that comes into contact with blood or body fluids must be disposed of properly. Needles must not be recapped, but rather placed in a sharps container immediately after use on a patient.

Spirometry testing

Spirometry is an automated test that produces a graphic result. It is conducted similarly to the peak flow meter. The patient should wear loose clothing, sit in an upright or standing position, and breathe through the mouth, pursing the lips around the mouthpiece

Vision tests performed in ambulatory care

The medical assistant performs noninvasive screenings to detect visual abnormalities of the eye (hyperopia, myopia, presbyopia). Using charts and having the patient identify shapes or letters assists with the diagnosis

Near vision test

Near vision testing screens for presbyopia or hyperopia using a near vision acuity chart. Ask the patient to read printed material of various sizes 14 to 16 inches away from the eyes without corrective lenses. Test each eye separately and then both together.

Hearing tests performed in ambulatory care

Tympanometry records the movement of the tympanic membrane, which can be affected by increased pressure in the middle ear

VENIPUNCTURE

In preparation for the venipuncture, seat the patient in a comfortable, well-lit area. For patients who have a fainting history, the procedure may be performed with the patient in a semi-Fowler’s position (back of the patient table lowered to 45°) or laying down

Positioning the arm

Position the patient with the arm extended to form a straight line from the shoulder to the wrist and the palm of the hand facing upward

Arranging supplies

All necessary phlebotomy supplies, including the sharps container for needle disposal, should be within reach. During the procedure, hold the needle in the dominant hand, and avoid switching hands once the skin has been penetrated

Cleansing the site

Disinfect the site with 70% alcohol pads, moving in concentric circles of increasing diameter

starting from the anticipated needle insertion site. Allow the skin to air dry

Age determinants

Site selection is sometimes determined based on the patient’s age. Most often, newborns to infants

6 months of age need only a heel stick and capillary blood specimen unless extensive testing

is required

During site selection, check with the patient regarding possible medical restrictions due to fistulas, ports, or mastectomy

Evacuated tube method

The most commonly used technique for phlebotomy procedures is the evacuated tube or vacuum tube method. This collection method uses a straight double-ended needle and color-coded vacuum tubes made from glass or plastic.

Syringe method

While not commonly performed in the ambulatory care setting, the needle and syringe method of blood collection is still used in some circumstances

Butterfly method

Winged infusion or butterfly method is commonly used for smaller or more fragile veins in the dorsal hand, but can also be used in the antecubital area. The butterfly needle has replaced the syringe draw technique in the ambulatory care environment as the method of choice for weak or fragile veins.

PERFORM CAPILLARY PUNCTURE

Capillary punctures, also called finger sticks, are performed when only a small amount of blood is

needed for testing, or when immediate results are required.

Stress testing is typically completed in hospital environments where thorough monitoring and emergency equipment are available. One of the greatest risks associated with this testing is cardiac arrest. However, stress testing can be conducted in a cardiology specialty setting

ambulatory monitoring is fairly common in cardiology practice and sometimes in family practice. The medical assistant is responsible for attaching electrodes to the trunk and providing patient education

Abnormal rhythms

Arrhythmias originating from the sinoatrial (SA) node are easily detected.

Abnormal waves

The normal P wave should be positively deflected. In the event it is negatively deflected, junctional dysrhythmia is likely to present. This means that the typical impulse pathway from the SA to the atrioventricular (AV) node is not occurring. The initial impulse is originating in the AV junction, AV node, or from some ectopic source

reception room environment reception room should be appealing, welcoming, and clean. Throughout the day all magazines, office brochures, and educational patient material should be picked up and stacked neatly.

Identifying and greeting patients patient’s first impression often leaves a lasting perception of an office and the staff. Greet patients politely as they enter the building and as they complete their visit

Collecting payments is important to review the patient insurance information for each visit to ensure the correct fee is collected. Insurance policies and allowed amounts can vary greatly. Some patients are responsible for the full allowed amount, which applies to their deductible before the coinsurance amount applies to patient responsibility. Other insurance policies have a specifically contracted copayment due at the time of service.

sign provide all patients with consent to treat form to review and sign before the provider can move forward with any treatment. Written informed consent is required when an invasive procedure or treatment will be performed. Any situation that requires an in-depth understanding of a treatment or procedure needs informed consent signed in advance.

ICD-10-CMICD-10-CM

coding was implemented on October 1, 2015, after unexpected delays by Congress. ICD-10-CM coding contains approximately 55,000 more codes than ICD-9-CM and allows more specific reporting of diseases and newly recognized conditions.

CD-10-Procedure Coding System (ICD-10-PCS)

is a system comprised of medical classifications for procedural codes typically used within hospitals that record various health treatments and testing

National Healthcareer AssociationCCMA Focused ReviewAdministrAtive AssistingCPT codes and modifies current Procedural Terminology (CPT) codes and modifiers are used to document procedures and technical services based on services by providers in outpatient settings

Healthcare Common Procedure Coding System (HCPCS) is a group of codes and descriptions that represent procedures, supplies, products, and services not covered by or included in the CPT coding system. Similar to CPT codes

FILLING SYSTEM AND SERVICES

Conditioning involves grouping related papers together, removing all paper clips and staples, attaching smaller papers to regular sheets, and fixing damaged records.

Releasing

is marking the form to be filed with a mark of designated preference (ready to be filed,

the provider’s initials, using a stamp).

Indexing and coding

are determining where to place the original record in the file and whether it

needs to be cross-referenced in another section. A chart number is typically used for this

Sorting

involves ordering papers in a filing structure and placing the documents in specific groups

Storing and filing

is securing documents permanently in the file to ensure the medical record

documents do not become misplaced.

Alphabetic filing

is a traditional system for patient records in providers’ offices and is the most

widely used. Files are arranged by last name, first name, and middle initial.

Numeric filing

is typically combined with color coding and used for larger health centers or

hospitals. This method allows for unlimited expansion without the need to shift files to create

room. It saves time for retrieving and filing charts and provides additional patient confidentiality.

Subject filing

is used for general correspondence using the alphabetic or alphanumeric filing

method. With this method, all correspondence dealing with a particular subject is placed under a

specific tab with subject headings

RESOLVING BILLING ISSUES WITH INSURERS AND THIRD-PARTY PAYERS

There are two primary reasons claims are denied or rejected: technical errors and insurance policy

coverage issues. Medical assistants can reduce claim issues with insurers and third-party payers by ensuring insurance is verified prior to the patient being seen and that guidelines are followed when reviewing claims prior to submission.

Sharing information within an organization for business purposes is considered internal communication.

External communication is the transmission of information between a business and another person or entity outside of the company’s environment

Preparing faxes

Fax machines are still used in the healthcare industry. Fax machines allow documents to be securely transmitted with end-to-end encryption.

Mutual assent:

An agreement by all parties to the contract; must prove there was an offer and

acceptance

⦁

Consideration:

A benefit of some type for entering into the contract, such as financial

reimbursement

⦁

Capacity:

Parties must be legally able to contract (legal age and of sound mind)

⦁

Legality:

Subject matter must be lega

Administrative law is the body of law in the form of decisions, rules, regulations, and orders created by administrative agencies under the direction of the executive branch of the government used to carry out the duties of such agencies.

Affordable Care Act (ACA):

The ACA was put in place to reform the healthcare system by providing

more Americans with affordable, quality health insurance to ultimately curb the growth in health

care spending in the United States

occupational Safety and Health Administration (OSHA):

OSHA states that employers are accountable for providing a safe and healthful workplace for employees by setting and enforcing standards and by providing training, outreach, education, and assistance

Health Insurance Portability and Accountability Act of 1996 (HIPA A):

HIPAA gives patients rights over their health information and sets rules and limits on who can look at and receive patients’ private information.

Controlled Substances Act (CSA):

CSA is a federal policy that regulates the manufacture and

distribution of controlled substance

Title VII of Civil Rights:

Title VII of the Civil Rights Act prohibits an employer with 15 or more

employees from discriminating on the basis of race, national origin, gender, or religion.

Americans with Disabilities Act (ADA):

ADA forbids discrimination against any applicant or employee who could perform a job regardless of a disability. ADA also requires an employer to provide accommodations that are necessary to help the employee perform a job successfully unless these accommodations are unduly burdensome

Family Medical Leave Act (FMLA):

FMLA is a federal law that requires certain employers to give time off to employees for familial or medical reasons.

he Joint Commission (TJC):

Accreditation with TJC helps organizations position for the future of integrated care, strengthen patient safety and the quality of care, improve risk management and risk reduction, and provide a framework for organizational structure and management

tort

is an action that wrongly causes harm to an individual but is not a crime and is dealt with in a

civil court. There are two major classifications of torts: intentional and negligence