ancillary services and alternative therapies

Providing ancillary services in the provider’s office adds convenience for patients and increases

revenue for the organization. Ancillary services meet a specific medical need for a specific

population. For example, an occupational therapist assists patients to acquire day-to-day physical tasks that they have never been able to do or recovering those lost due to an illness or injury. Urgent care offers more locations and time flexibility to patients who might have cold-like symptoms.

Types of ancillary services

1. 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-in 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

Commonly prescribed medications and commonly approved abbreviations

COMMON MEDICATIONS AND ABBREVIATIONS

Thousands of medications are available for providers to prescribe, so it might seem overwhelming to learn about all of them. However, medical assistants tend to encounter the same commonly prescribed medications over and over. Working knowledge of those medications and the various common medication classifications will provide the knowledge and confidence needed to assist patients with medication therapy. For example, it is not necessary to know everything about every antibiotic, but a working knowledge of antibiotics, in general, is useful in encounters with patients who have bacterial infections.

Commonly prescribed medications

Medication therapy changes often enough to make it essential to consult reference materials and websites often. New medications become available all the time, and medications go off the market often enough that it’s helpful to make a habit of checking websites like drugs.com, rxlist.com, pdr.net, and fda.gov for the latest information. The U.S. Food and Drug Administration provides black box warnings that prominently state potential new and life-threatening risks of taking a specific medication. It is useful to subscribe to websites that send information about changes in medication therapy, such as Medscape.

com or WebMD. com. Checking fda.gov can also provide the latest information about black box warnings. The medications prescribed most often are a good place to start. Multiple websites list the top medications by sales, but this doesn’t reflect common practice. That is because some brand-name medications do not have generic forms and are extremely expensive, so they might be on top, even if providers don’t prescribe them as often as some other generic medications. These lists can still give a good idea of the most common medications. (Because there are multiple brand names for medications, these materials will only cover generic names. Medical assistants should be familiar with both.

Commonly approved pharmacological abbreviations

Medical assistants see many pharmacological abbreviations daily. The Joint Commission and the Institute for Safe Medication Practices have identified some as “do not use” and “error-prone abbreviations.” Avoiding these abbreviations is essential. For the full lists, see the Joint Commission and the Institute for Safe Medication Practices websites. The following abbreviations are acceptable

MEDICATION CLASSIFICATIONS AND SCHEDULES

Knowledge of medication classifications and schedules is essential when assisting providers and helping patients understand what their medications should do. Learn the risks

the federal government has identified with some medications and why it has limited its

prescribing and dispensing patterns. The U.S. Drug Enforcement Administration (DEA) has

designated some medications as controlled substances and assigned them to five schedules. These are primarily medications that have a potential for abuse and illicit use or do not have any approved medical use in the United States. The schedules change as new medications become available and the DEA determines that a medication already on the schedule has more or less potential for abuse. Prescribing rules also change. For some schedules, providers must issue handwritten prescriptions, but that might change as exclusively electronic prescribing (e-prescribing) becomes standard practice

Medication classifications and their uses

The classification of medications is complex. Primarily, a medication’s therapeutic action

dictates the classification, but sometimes it is done by chemical formulations, body systems they act on, or symptoms the medication relieves. Some medications fall into more than one category. Gabapentin and pregabalin are good examples. Both medications are anticonvulsants; they treat seizures. However, they are also analgesics, because they help relieve neuropathic (nerve) pain. Another example is hydrochlorothiazide, a diuretic—it helps eliminate excess fluid from the body. However, in doing so, it can help lower blood pressure; thus it is also an antihypertensive medication. Here are some of the most common classifications of medication medical assistants are likely to encounter

Medication schedules

The federal Controlled Substances Act (CSA) created five schedules for controlled substances,

according to their potential for abuse and addiction. Only controlled substances are

scheduled.

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 I still includes cannabis (marijuana) even though it is legal in many states for medical use with a prescription.

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. In healthcare facilities, staff members must keep these in a secure, locked cabinet or storage area separate from other medications.

Schedule III:

includes substances that have a moderate to low potential for physical and

psychological dependence. These include ketamine, anabolic steroids, and testosterone. Providers must give patients a handwritten prescription. They may refill them five times in 6 months.

Schedule IV:

includes substances that have a low potential for abuse and dependence. These include diazepam, zolpidem, eszopiclone, alprazolam, chlordiazepoxide, and clonazepam. Providers must sign prescriptions for these substances, and patients may refill them five times in 6 months. Staff members may authorize refills over the phone.

Schedule V:

includes substances that contain limited quantities of 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. Staff members may authorize refills over the phone.

For a current alphabetical list of all controlled substances and their CSA schedule number, go to the resources section of the Office of Diversion

Dietary Nutrients

Nutrients are essential food substances—the organic and inorganic

materials the body needs for energy and cellular activities like growth, repair, disease resistance, fluid balance, and thermoregulation. Some nutrients are essential, meaning the body cannot produce them. For example, some protein components have to come from foods. Nonessential nutrients are those the body can make. Examples are vitamin D and

cholesterol, which do not have to come from the diet. The body has to break down all the nutrients in the diet into substances it can use. This process begins with

digestion. Nutrients that contain calories are proteins, carbohydrates, and fats (lipids).

Other nutrients might be in foods that contain calories, but water, vitamins, minerals, and fiber

themselves do not contain calories. A balance of these nutrients in the diet is essential for everyone, but especially for children, pregnant patients, and older adults.

The body needs energy for every function it performs—even during sleep because its organs and systems are still functioning. Energy comes from the three nutrient groups that contain calories:

proteins, carbohydrates, and fats. How much energy (or how many calories) a person needs depends on multiple factors, including basal metabolism, activity level, age, sex, and various disorders. Most young adults need 1,800 to 2,200 calories per day. Those who exceed that caloric intake regularly can gain weight and might become

obese. Those who do not meet their caloric requirements routinely can lose weight and possibly become malnourished. A quick way to get an estimate of where a patient falls on the continuum between underweight and obese is to calculate body mass index (BMI). Many such calculators are available online or in mobile apps. The formula is to divide the patient’s weight (in kilograms) by height (in meters) squared

• Encourage patients to follow a diet that is low in fat, high in fiber from plant sources and whole grains, stays within caloric limits, provides a healthy balance of nutrients, and avoids highly processed foods. Healthful diets can go off track occasionally. It is common to consume sugary beverages instead of water with and between meals. Restaurant dining typically results in servings

that exceed caloric recommendations (portion distortion). It is a challenge to help patients who

frequently indulge in these habits to undo them and get back on track nutritionally, but their lives, health, and well-being depend on it

Major nutrients and their functions

Water

• 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. Although

almost every food and beverage contains water, it is recommended that

people still drink 2 to 3 L (64 to 96 oz) each day for optimal health.

Water has many functions, including transporting nutrients and oxygen

throughout the body, helping remove wastes, regulating body temperature through perspiration,

and providing the basic component of blood and other bodily fluids. The body loses water

throughout the day in urine, stool, sweat, and water vapor in breath—a total of 1,750 to

3,000 mL each day. Ideally, the body needs to balance intake and output, replenishing fluids

the body eliminates with drinking water. Except oils, almost all foods contain water. Fruits and vegetables contain the most water, but people should not just rely on the fluid that food and flavored beverages contain. Thirst is a good indication that the body needs more water, and pale-colored urine (nearly clear) is a good indication of adequate hydration. It is especially important to consume adequate water during extreme exercise, in hot environments, and during illness. 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. Bottled water is popular and convenient, but public water supplies are adequate for providing the water the body needs. Added vitamins, minerals, herbs, flavorings, sugar, caffeine, and coloring are unnecessary. Caffeine can act as a diuretic, eliminating water the body might need.

Proteins

Proteins are large, complex molecules the body makes from amino acids, which are

the natural compounds that plants and animal foods contain. There are three types

of amino acids.

• 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.

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

Nonessential does not mean unnecessary; the body needs all 20 amino acids for optimal

functioning. The body uses amino acids to repair and build tissues. The body can also use protein for energy if other sources (carbohydrates, fats) are not readily available. Using protein for energy is wasteful, because, over time, the body will lose lean tissues and muscle strength will diminish. Proteins also contribute to the body’s structure, fluid balance, and creation of transport molecules. Because the body does not store amino acids, it is important to consume protein every day. Each gram of protein provides 4 calories. Too little protein causes weight loss, malnutrition, fatigue, and increased susceptibility to infection. Too much protein will wind up as body fat or be converted to glucose. The body requires additional protein when recovering from burns, major infections, major trauma, and surgery. Additional protein is also important during pregnancy, breastfeeding, infancy, and adolescence

Carbohydrates

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. Depending on their structure, they are either simple

sugars (honey, candy, cane sugar) or complex carbohydrates (fruits, vegetables, cereal,

pasta, rice, beans, whole-grain products). Simple sugars have one or two sugar molecules,

while complex carbohydrates are long chains of hundreds to thousands of sugar molecules. Complex carbohydrates include starch, which is the glucose plants do not need immediately for energy. It is stored in seeds, roots, and stems. Sources of starch include potatoes, wheat, rice, corn, barley, oats, and some other vegetables. Fiber is another complex carbohydrate.

The body uses carbohydrates primarily for energy for its cells and all their functions. Glucose is

the simple sugar the body requires for energy needs, and the body burns it more completely and efficiently than it does protein or fat. Therefore, it has the important function of sparing protein so that it is available for functions such as replenishing blood cells and healing wounds. Through digestion, the body converts all other digestible carbohydrates into glucose. When the supply of glucose exceeds the demand, the body stores glucose in the liver as glycogen, a ready source of energy when the body needs it. The body can use glucose to create nonessential amino acids from available essential amino acids. It can also use glucose to make some other compounds in the body; but after that, excess glucose becomes body fat. Each gram of carbohydrate provides 4 calories. Too little carbohydrate in the diet results in protein loss, weight loss, and fatigue. Too much can lead to weight gain and tooth decay.

MyPlate quantifies requirements for fruits, vegetables, and grains separately. Protein foods also contain carbohydrates. Dairy is a separate category because dairy products typically contain protein, fat, and carbohydrates. MyPlate discourages sweet desserts and snacks, soft drinks, candy, and other products that have added sugars because they are high in calories but low in nutritional value. The added sugar provides “empty calories.” These should be treats to consume in small portions only.

• Drinking water, unsweetened tea or coffee, or other calorie-free beverages instead of sodas or other sweetened beverage

• Choosing beverages that will help fulfill daily requirements in the dairy and fruit group, such as low-fat or fat-free milk and 100% fruit juice

• Choosing fruit as a naturally sweet dessert or snack instead of foods with added sugars

• Choosing packaged foods that have low or no added sugars (plain yogurt, unsweetened applesauce, frozen fruit without added sugar or syrup

Fats

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 heavy. They are oils and have less potential for raising cholesterol levels (thus causing heart disease) than saturated fats do. Unsaturated fats can be monounsaturated (olive, canola, and peanut oil) or polyunsaturated (corn, sunflower, and safflower oil) like carbohydrates, they are made of carbon, hydrogen, and oxygen, but the arrangement is different. Fat molecules contain fatty acids. Chemically, the distinctions between fatty acids and the types of fats they form are complex. For dietary purposes, the important difference is the degree of saturation.

• Trans fat is a fatty acid used to preserve processed food products. It is a byproduct of solidifying polyunsaturated oils (a process called hydrogenation) and raises LDL (“bad”) cholesterol levels.

• Saturated fats are solid at room temperature. Primarily from meat products as well as palm and coconut oil, this type of fat also raises LDL. There is no cholesterol in other plant foods

Fat is an important nutrient that is essential for the absorption of fat-soluble vitamins. Fats

provide structure for cell membranes, promote growth in children, maintain healthy skin, assist

with protein functions, and help form various hormone-like substances that have important roles like preventing blood clots and controlling blood pressure. Stored fat has the protective function of insulating and protecting organs. Each gram of fat provides 9 calories. Too little fat in the diet can cause vitamin deficiencies, fatigue, and dry skin. Too much fat can cause heart disease and obesity. MyPlate recommends minimizing the intake of saturated and trans fats. Foods that are high in saturated fats include whole-milk dairy products, egg yolks, butter, cream, ice cream, mayonnaise, whole-milk cheeses, meat (especially red meat), oil-packed fish, shortening, lard, and coconut and palm oils. Read food labels and look for products that specify “no trans fat.” A label that reads “zero trans fat” could have up to 0.5 g (numbers less than 0.5 round to zero), so it is best to avoid those products. even small amounts of trans fats can add up

Fiber

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. It has important functions.

• Slowing the time food takes to pass through the stomach, thus providing a feeling of

  the fullness that discourages overeating

• Adding bulk to the stool to promote normal defecation

• Absorbing some wastes for easier elimination in the stool

• Lowering cholesterol levels

• Slowing glucose absorption

A diet rich in fiber helps prevent constipation, gallstones, hemorrhoids, irritable bowel syndrome, and diverticulosis. It also helps with managing diabetes mellitus and reducing the risk of colon cancer

Although fiber itself does not provide calories, the reactions it causes in the intestines can produce some fatty acids. So fiber provides an estimated 1.5 to 2.5 calories per gram. Too little fiber increases cancer risk and blood glucose levels after eating, and also causes constipation. Too much fiber can interfere with mineral absorption and cause gastrointestinal problems (bloating, diarrhea). Sources of fiber include whole grains, beans, nuts, fruits, and vegetables. A tip from MyPlate is that a product that provides at least 3 g of fiber per serving is a good source of fiber. A product that contains 5 or more grams of fiber per serving is an excellent source of fiber. It is also important to note that fiber needs water to perform its essential functions in the body. Adequate intakes of fiber and water go hand in hand

Vitamins

Vitamins are organic substances the body needs for various cellular functions. Each vitamin

has a specific role. Except for 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. Vitamins do not provide energy, but they are necessary for the body to

metabolize energy. Some manufacturers add vitamins to products to make them more nutritious. Examples are fortified cereals, juices, and milk. Some vitamins (C, E) can help some foods last longer. Vitamin E can help keep vegetable oils from becoming rancid. In large doses, some vitamins have medicinal purposes. For example, large doses of niacin can help lower cholesterol, and vitamin C can help with bone and wound healing

The major classification of vitamins is according to their solubility. This means that their absorption, transportation, storage, and excretion depend on the availability of the substance in which they dissolve.

• Fat-soluble vitamins: A, D, E, K

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

Minerals

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. They provide the rigidity and strength of the bones and contribute to muscle contraction and relaxation. They also help regulate the body’s acid-base balance and are

essential for normal blood clotting and tissue repair. They are cofactors for

enzymes, which means they assist those substances in performing their metabolic functions

The major classification of vitamins is according to how much the body needs each day.

• Major minerals should be consumed in amounts of 100 mg or more to promote health and avoid

deficiencies. These include calcium, sodium, potassium, phosphorus, and magnesium.

⦁Trace minerals are needed in 20 mg or less each day. These include iron, iodine, zinc, copper,

fluoride, selenium, chromium, manganese, and molybdenum

iron is not a major mineral but is on this list because of its importance for the production of red blood cells. Iron deficiency anemia can cause problems, especially for infants and children.

End-of-life stages

As people age and their physiologic abilities and reserves dwindle, they tend to seek more health care servException in pediatric settings, many of the patients who medical assistants will encounter in their daily practice will be in their last few decades of life.

After age 60, many people start to think about r mortality. They realize that so much of

their life is behind them, and they begin to wonder how many “good years” they have left. For

many, their adult children live long distances away and have families and careers of their own. It gradually becomes more difficult for older adults to continue to work, maintain homes, and— depending on what health conditions they have—participate in activities they enjoy (gardening, tennis) as well as activities of daily living. They worry that minor issues, like forgetting to buy an item they need at the grocery store or misplacing their mean they are developing dementia. Those whose capacity for independent living has diminished can become victims of elder abuse, which can involve neglect or physical abuse, often perpetrated by caregivers or family members who are overwhelmed with the burden of caring for the aging individual. Many older adults deal with constant grief, as older friends, neighbors, and family members die. They may also grieve for themselves—for their younger, healthier days and for the abilities they are losing or have lost. They hear many clichés, such as “Just take one day at a time,” “Don’t worry about what hasn’t happened yet,” and “You’re only as old as you feel.” But the reality is that these platitudes offer little comfort to older adults grappling with the grim realities of aging. All patients need support when they encounter the health care system, but medical assistants must realize that older adults are a unique population because they face so many challenges toward the end of life. The physical challenges are real, and the feelings of grief can be overwhelming. This leads to a major health concern for older adults: depression.

End-of-life struggles

Many older patients have chronic or even terminal illnesses that influence them to prepare for the end of their life. It is not uncommon for a provider to tell a patient who has a life-threatening

illness, such as advanced cancer or kidney disease, that it is time to “get their affairs in order.” This means that patients should make arrangements for end-of-life care, funeral, burial, and cremation services. If the person has a dependent, such as a partner, the dying person will want to make financial or caregiving arrangements for the dependent. The person also needs to have

advance directives in place, as well as a will and a

durable power of attorney for healthdocumentscument available.

These preparations bring the reality of the end of life into sharp focus, and generally put the patient and loved ones into a state of anticipatory grief. This means that they are feeling the emotions and reactions that grief causes before the loss actually occurs

Stages/cycle of grief (Kübler-Ross)

Just like with developmental stages, several theorists have defined the

various stages of grief. The most well-known theory is the five stages of

grief Elisabeth Kübler-Ross defined as a result of her extensive experience

in working with dying patients. Awareness of these stages can help

medical assistants understand what grieving patients are experiencing,

whether the loss is the death of a loved one, a loss of a body part or

function, a financial loss, the loss of a home, or any number of other

losses that have a strong and lasting effect on the person.

It is important to understand that not everyone grieves in the same way. While one person might navigate through the stages of grief one by one and in sequence, others can be in more than one stage simultaneously. Some might even skip one of the stages. The duration of the process is also highly variable. There is no “right way” to grieve. The stages of grief that Kübler-Ross defined are

Denial

During this stage, the grieving person cannot or will not believe that the loss is happening

or has happened. He might deny the existence of the illness and refuse to discuss therapeutic

interventions. Thought processes reflect the idea of “No, not me.” The medical assistant should

try to support the patient without reinforcing the denial. It might help to give the patient written

information about the disease and treatment options.

Anger

During this stage, the grieving person might aim feelings of hostility at others, including health

care staff (because they cannot fix or cure the disease). Thought processes reflect the idea of “Why me?” The medical assistant should not take the patient’s anger personally but should instead help him understand that becoming angry is an expected response to grief

Bargaining

During this stage, the grieving person attempts to avoid the loss by making some kind of deal, such as wanting to live long enough to attend a particular family occasion. The patient might also be searching for alternative solutions. He is still hoping for his previous life, or life itself, or at least a postponement of death. Thought processes reflect the idea of “Yes, me, but...” The medical assistant should listen with attention and encourage the patient to continue expressing his feelings.

Depression

During this stage, the reality of the situation takes hold, and the grieving person feels sad, lonely, and helpless. For example, he might have feelings of regret and self-blame for not taking better care of himself. He might talk openly about it or might withdraw and say nothing about it. Thought processes reflect the idea of “Yes, it’s me.” The medical assistant should sit with the patient and not put any pressure on him to share his feelings but instead convey support and understanding. Referrals to a support group or for counseling can be helpful

Acceptance

During this stage, the grieving person comes to terms with the loss and starts making plans for

moving on with life despite the loss or impending loss. He is willing to try to “make the best of it” and formulate new goals and enjoy new relationships. If death is imminent, he will start making funeral and burial arrangements and might reach out to friends and family who have not been a part of his recent years of life. There might still be some depression, but there might also be humor and friendly interaction. Thought processes reflect the idea of “Yes, me, and I’m ready.” The medical assistant should offer encouragement, support, and additional education to the patient and his family and friends during this time.

ROLES AND RESPONSIBILITIES

Medical assistants, along with other healthcare staff, function as members of a healthcare team that perform administrative and clinical procedures and responsibilities. Medical assistants often screen patients before the provider visit. The provider then assesses the patient and determines if further medical testing is necessary. Depending on the patient’s current condition, the provider may send the patient for allied health services (phlebotomy, physical therapy). Whether services are provided in a hospital,

ambulatory care center, home health agency, hospice, medical personnel

are ultimately responsible for the care and well-being of their patient

Roles and responsibilities of the medical assistant

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. In addition, the medical assistant is often responsible for the clinical tasks of obtaining medical histories from patients, explaining treatments or procedures, drawing laboratory tests, and preparing and administering immunizations. A medical assistant can also achieve credentialing by passing a national certification exam.

Roles and responsibilities of healthcare providers

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

Roles and responsibilities of allied health personnel

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.

ROUTES OF ADMINISTRATION

Medical assistants use and discuss many different routes for using medications with patients.

Providers must include the route of administration on every prescription to avoid undesirable effects that can occur with giving medication by the wrong route. The most common routes fall into two general categories: enteral (through the gastrointestinal tract) and parenteral (outside the gastrointestinal tract). Literally, parenteral would include routes like topical and vaginal. However, in common usage, parenteral refers to injections—intramuscular, intradermal, subcutaneous, and intravenous. Medical assistants do not give medications by routes that require nurses or providers: intravenous, epidural, intrathecal, and others.

Anatomy and physiology

COMMON NONPATHOGENS AND PATHOGENS

Some microorganisms are helpful or do not cause disease under normal circumstances. These are nonpathogens. For example, the bacteria in the gastrointestinal tract, such as Lactobacillus acidophilus, assist with digestion. Probiotics (microorganisms that promote health) have become popular dietary supplements. They are live micro-organisms (usually bacteria) that are similar to the beneficial micro-organisms in the gastrointestinal tract. Proponents make claims about the health benefits of using these often costly supplements, and there is some evidence probiotics are helpful with digestive disorders and in preventing diarrhea that easily results from antibiotic therapy. However, the validity of other health claims is still uncertain, as is the safety of probiotics in supplementing the form. Remind patients that probiotics are available in much less costly products (yogurt, sauerkraut, kimchi [Korean-style fermented vegetables]). Some microorganisms are not so helpful. These are pathogens, the micro-organisms that cause infectious diseases and infestations. Everyone is at risk for the infections and infestations pathogens cause, but those whose immunity is low, such as patients receiving chemotherapy to treat cancer and those who have acquired immunodeficiency syndrome (AIDS), are at especially high risk. Infection can also result when microorganisms are usually present in the body, and its normal flora, “overgrow” for any of a variety of reasons. The following tables list disease-causing pathogens by classifications

ORGANISMS AND TYPES OF MICRO-ORGANISMS

Organisms are any living things. Microorganisms are tiny (often one-celled) living things. Medical assistants should be aware of the various categories of microorganisms that typically cause infections and other disorders.

Common pathogens and non-pathogens

Here are the most common categories of micro-organisms. Others, such as algae, are not major causes of common diseases

Bacteria

A bacterium is a single-cell microorganism that reproduces rapidly and causes many different infections. It can survive without other living tissue. Bacteria have various classifications according to their shape, cell-wall structures, ability to retain some chemical stains, and whether they can grow with (aerobic) or without (anaerobic) air. Common shapes of bacteria are coccus (round), spirillum (spiral-shaped), vibrio (shaped like a comma), and bacillus (rod-shaped). There are also distinct groups of bacteria, such as rickettsiae, that live and grow only inside other living things, such as insects. People acquire these bacteria from insect bites. Antibiotics are medications that kill bacteria, so they are a major component of treatment plans for bacterial infections. However, with the overuse of antibiotic therapy over many years, some bacteria have developed resistance to antibiotics and are now difficult to kill. Examples are methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci. Bacteria and some other pathogens have a specific naming convention. The first word conveys the micro-organism’s genus, which is a biological classification between the family and the species. The second word is its species. Examples are Staphylococcus aureus, Pseudomonas aeruginosa , and Escherichia coli. Thus Staphylococcus epidermis is a bacterium that belongs to a group (genus) of other staphylococcal bacteria, and its species is the epidermis

Viruses

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. Because viruses need living tissue to reproduce, it can be challenging for laboratory technicians to grow or test them. Viruses are complex. When they invade, they attach to host cells in the person. Their genetic material then takes control of the host cells, destroying them and infecting nearby cells. Some viruses attack immediately, while others lie dormant and attack later. Viruses tend to change (mutate) during replication (reproduction), which makes it difficult to build adequate immunity to them. Some are difficult or impossible to kill with medications. Some antiviral drugs exist, but they have various degrees of effectiveness against some viruses. Common viruses include the human immunodeficiency virus (HIV), influenza viruses, and human papillomavirus (HPV)

Fungi

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 disease. Those that do tend to

cause superficial infections like athlete’s foot and vaginal yeast infections. People who have a weakened immune system, however, are at risk for much more serious internal fungal infections. Fungi can have useful functions. For example, fungi are a source of antibiotics. There are some micro-organisms that have the characteristics of a fungus but also of another classification. For example, Pneumocystis carinii, which causes a specific type of pneumonia, has some properties of fungi and some protozoa

Protozoa

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. An example of a disease-

causing protozoon is Entamoeba histolytica, an ameba that causes dysentery, a severe type of diarrhea.

Multicellular parasites

Although this category does not fit the definition of microbiology, these organisms cause infections and infestations. Examples are lice, bed bugs, scabies, and pinworms

ANATOMICAL STRUCTURES, LOCATIONS, AND POSITIONS

It is important to be familiar with tissues, organs, and body systems in order to communicate

and provide optimal care to patients. Each of these divisions of the body has specific duties and locations, which medical assistants should easily recognize. The human body can be studied according to each structure and how it functions.

ANATOMICAL POSITION AND DIRECTIONAL TERMS

When healthcare personnel refer to a patient’s body or body systems,

anatomical position is used, regardless of how the patient is actually positioned. By using this universal reference point, there is no question in the documentation or description of the body. Anatomical position is described as the body standing flat-footed, with toes forward, legs straight, arms at the sides, and the head and palms facing forward

Directional terms are also commonly used in a medical office. Proper use

and interpretation of these terms ensure accurate communication and

documentation.

Superior (cranial): Above or closer to the head. The esophagus is superior to the stomach.

Inferior (caudal): Below or closer to the feet. The bladder is inferior to the kidneys.

Anterior (ventral): Toward the front of the body. The sternum is anterior to the spine.

Posterior (dorsal): Toward the back of the body. The sacrum is posterior to the pubis symphysis.

Medial: Closer to the midline of the body. The tibia is the

medial bone of the lower leg.

Lateral: Further away from the midline of the body. The radius is

lateral to the ulna.

Proximal: Closer to the trunk of the body. The proximal femur articulates with the pelvis to form the hip joint.

Distal: Farther away from the trunk. The distal humerus helps to form the elbow.

Superficial: Closer to the surface of the body. Veins are superficial to arteries.

Deep: Farther from the body’s surface. Arteries are deeper than veins

Planes of the body

Three main planes are used to describe sections of the body and are also frequently used in various radiographic studies. It is important to be familiar with these planes

and the correct usage of these terms when discussing or documenting locations.

Sagittal plane: Divides the body into left and right sides. Midsagittal refers to an equal division of left and right sides, running along the midline of the body.

Transverse plane: Divides the body into upper and lower sections, not necessarily equally.

Frontal plane: Also called the coronal plane, divides the body into anterior and posterior sections

BODY CAVITIES

The human body can be studied according to each body of five cavities and their internal organs.

Cranial cavity: Within the bony cranium, houses the meninges (brain)

Spinal cavity: A continuation of the cranial cavity as it travels down the midline of the back

Thoracic cavity: Within the chest, houses the lungs, heart, and major vessels

Abdominal cavity: Within the abdomen, houses several major organs

Pelvic cavity: Inferior to the abdominal cavity, houses the bladder

BODY QUADRANTS AND REGIONS

The human body can be divided into quadrants or nine regions, either of which is helpful as

a reference during the physical examination of internal organs. Being familiar with each quadrant assists in correctly documenting a patient’s chief complaint.

General patient care

GUIDELINES FOR SENDING PRESCRIPTIONS AND REFILLS BY PHONE

The medical assistant cannot write or prescribe medications but is authorized to send medication prescribed by the provider to the pharmacy electronically or via phone. The medical assistant must be familiar with regulations regarding refills and controlled substances. Clear communication with the pharmacy is necessary to avoid mistakes and potential harm to the patient, which can lead to legal action against the provider and practice

Federal and state requirements

As part of recent federal requirements, only licensed or credentialed individuals may send

prescriptions electronically. To comply with this law, upon receiving the prescription for a

medication, the medical assistant must be credentialed to perform this function.

The medical assistant might need to call a refill to the pharmacy. When phoning a prescription,

speak clearly, provide the full name and birthdate of the patient, identify the medication being

prescribed, and avoid using abbreviations that could lead to a misunderstanding of the directions. Controlled substances identified by the DEA may not be called to the pharmacy; the patient must deliver the physical prescription to the pharmacy. For further information on controlled substances, go to the DEA website at www.dea.gov.

Parts of a prescription

To ensure a prescription is accurate, the pharmacy will only accept the prescription if all of

the parts identified on the prescription are completed. The same information is relayed to the

pharmacy whether the prescription is transmitted electronically or via phone

Methods for creating and sending prescriptions

Electronic health records in the ambulatory care setting allow prescriptions to be written and

transmitted to the pharmacy selected by the patient. Other methods of transmission include

faxing, phoning, or providing a written prescription. All of these methods are effective and

used for various circumstances. It is important to follow the policies and procedures identified

by the facility

Paper vs. electronic prescriptions

The chance of human error is reduced when using electronic prescriptions. The medical

assistant or the pharmacist does not need to interpret handwriting from the provider, which

reduces medication errors. Medications can also be rapidly sent and ready for the patient

upon arrival when electronic. In addition, the chance of medications being abused is reduced

when paper prescriptions are not available in the examination area or given to patients. Be alert

for patients who repeatedly contact the office stating they lost their written prescription and need another one or want the prescription called to a different pharmacy.

One of the downfalls of electronic prescriptions is the potential for network problems, which

could result in a failed or delayed receipt of prescriptions. In addition, the person transmitting the prescription must be credentialed, which limits who is authorized to handle this duty

Faxing prescriptions

Faxing is effective if a patient contacts the pharmacy for their medication and there are no refills. The pharmacy may choose to contact the provider via fax asking for authorization for refills. The medical assistant may be responsible for retrieving the fax and delivering it to the provider as well as communicating further instructions to the patient

ASSISTING WITH SURGICAL INTERVENTIONS

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

The goal of surgical intervention is to deliver treatment and prevent further damage. Skills in

assisting with sterile procedures is important to avoid complications as well as efficiently and

effectively deliver the necessary treatment.

Explaining the procedure and obtaining consent

The provider is responsible for obtaining consent for surgical procedures. However, the medical assistant needs to have the forms ready for the provider, serve as a witness on the form, and be available to answer basic questions or defer questions to the provider. No surgical interventions should be completed without the expressed written consent of the patient, parent, or guardian

Pre- and post-surgical instructions

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. Planned surgical procedures are often easier to instruct the patient as far as what to expect and how to prepare. Although the time is limited in an emergency situation, make an effort to allay fears by informing the patient on what to expect.

Postsurgical instructions include when to return for follow-up, contact information in case of

complications, signs of infection, and how to care for the wound. Patients are often anxious and have a difficult time remembering instructions following a trauma, so written information should be reviewed and sent with the patient.

Setting up for the procedure

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, so do not place items in

this area. Basic principles in maintaining a sterile field include the following.

⦁Open packages so that they can easily drop onto the sterile field or be grasped by the provider

without touching the outer wrapper.

⦁Lip the bottle of liquids prior to pouring them into sterile containers.

⦁Do not leave a sterile field unattended, reach over a sterile field, or turn your back to a sterile

field.

⦁Medication vials should be cleaned with alcohol prior to holding with two hands for the provider

to inject the needle into.

Minor surgery procedures

Minor surgical procedures are often completed in the ambulatory care setting. The medical assistant is responsible for preparing the patient for the procedure, obtaining a brief history including documentation of allergies, and collecting vital signs. Postprocedure responsibilities include ensuring the patient has follow-up appointments and instructions. Many clinics require the medical assistant to communicate with the patient via phone within 24 hr of the procedure to check on progress. Some common procedures are listed in the following table.

MEASURING VITAL SIGNS

Vital signs are key indicators of homeostasis. Alterations in these values could indicate an

imbalance, which could be a precursor of illness or disease. Factors such as stress, food or liquid intake, medical conditions, age, and physical activity can affect vital signs. It is extremely important to be proficient in obtaining vital signs as well as knowledge of normal and abnormal values to effectively communicate with the provider and deliver education to patients. Accurate charting serves as a key communication tool among healthcare professionals.

Temperature

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 an infection. Fever is the body’s natural defense to fight invasive organisms and is therefore a normal reaction to illness. Patients who have a fever can present with chills, anorexia, malaise, thirst, and generalized aching. Temperature is measured orally via a digital thermometer, aurally using a tympanic thermometer, or temporally using a temporal artery scanner. Axillary and rectal temperatures determine skin and core temperature but are not commonly performed. Ingesting hot or cold liquids prior to taking an oral temperature and cerumen in the ear when taking a tympanic temperature can result in inaccurate results. Normal oral, tympanic, and temporal temperatures are 98.6° F (37° C). The axillary temperature will be 1° F cooler on average, while rectal temperatures average 1° F higher. Take into consideration temperature results, patient history, and clinical appearance.

Heart rate

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 particular circumstances.

⦁The radial pulse, located on the thumb side of the wrist, is the most common site for taking

an adult pulse.

⦁The brachial pulse, inside the upper arm, is the most common for children.

⦁The carotid, located in the neck just below the jaw bone, is most common for use in emergency procedures.

Other locations reflect circulation distal to the pulse site. For instance, a strong femoral

pulse demonstrates circulation being sent to the lower extremity. If a pedal pulse is absent,

circulation to the toes is affected. In addition to palpation, the pulse can be determined through auscultation. The apical pulse is counted by listening to the heartbeat at the apex of the heart. Auscultation is also incorporated when taking blood pressure. Pulse is evaluated on rate, rhythm or regularity, and volume or strength. A pulse can be described as 70/min (rate), regular (rhythm), and thready (strength). Thready reflects a pulse as difficult to detect or faint. Bounding describes a pulse as being very strong. Pulse rates depend on the patient's condition and age. Time of day, activity level, and medications can also affect heart rate. Average heart rates tend to slow with age, as identified in the following chart

Respiration

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. For example, a patient might have a rate of 28/min with an irregular rhythm and shallow depth. This would indicate some form of respiratory distress, as all three notations are abnormal. One respiration includes an inhale and exhale. The normal respiratory rate in a newborn average 30 to 50/min compared to an adult rate of 12 to 20/min. When observing the chest, the respiratory rate is counted, but when incorporating auscultation, the medical assistant may hear abnormal sounds that include wheezing, rales, or rhonchi. All of these are abnormal and the provider should be notified.

Blood pressure

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, blood pressure cuff, and stethoscope. Electronic equipment

can interpret blood pressure without auscultation. However, it is important to be able to accurately determine blood pressure both manually and electronically.

Measured in millimeters of mercury (mm Hg), the systolic pressure

is recorded when the first sharp tapping sound is heard, which is when the blood begins to surge into the artery that has been occluded by the inflation of the blood pressure cuff. The

diastolic pressure is noted when the last sound disappears

completely and the blood is flowing freely. These two readings are phases I and V of the

Korotkoff sounds, or distinct sounds that are heard throughout the cardiac cycle. In phase II, there is a swishing sound as more blood flows through the artery. In phase III, sharp tapping sounds are noted as even more blood is surging. In phase IV, the sound changes to a soft tapping sound which begins to muffle Blood pressure readings vary based on age, internal conditions, and external influences. Genetics also plays a role in a predisposition to developing hypertension. Blood pressure tends to rise with aging. Infants and children average blood pressures between 60/30 to 100/80 mm Hg, whereas adult normal blood pressure ranges from 100/60 to 140/80 mm Hg. However, blood pressure lower than 119/79 mm Hg is still considered normal. Blood pressure 140/90 mm Hg or higher is hypertension. Between 120 and 139 for the top number or 80 to 89 for the bottom number is prehypertension; options are often discussed with the patient to assist in lowering this reading.

Pulse oximetry (oxygen saturation)

Although usually not considered a vital sign, 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. A patient experiencing symptoms associated with lung conditions such as pneumonia, asthma, or bronchitis are candidates for this noninvasive assessment. A probe is attached to the finger that incorporates an infrared light to obtain the reading. Nail polish blocks light and interferes with the results, and should be removed prior to the test. Alternatively, the probe could be clipped to the earlobe instead of the finger if necessary. A pulse oximeter reading of 95% or higher is considered a normal result.

Pain scale

Pain is subjective and therefore difficult to interpret. Observe the patient to gather clues about the level of pain, such as facial grimacing or holding body parts. However, 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. Ask additional questions to determine the location, onset, and characteristics of the pain, and whether methods used for relief have been effective.

EYE, EAR, AND TOPICAL MEDICATIONS

Prior to administering medications to the ears or eyes, ensure the medication is at room

temperature, the patient is properly positioned, and gloves are worn during administration. The

tip of the containers should not come in direct contact with the patient, as this could lead to

contamination of the solution. Apply the same principles when administering topical medications. Take precautions not to touch topical medications. In addition to contamination concerns, medications applied topically can absorb into the body and lead to adverse reactions. Use an applicator to apply topical medications.

PREPARING AND ADMINISTERING MEDICATIONS AND INJECTABLES

Administering medications requires consistent diligence. Even simple errors can lead to adverse reactions. For additional details on medication administration, refer to Chapter 3: Pharmacology.

Checking the medication order

The name of the medication, dosage, time, and route of administration direct the medical assistant in preparing the medication for administration. Consent for the administration of medication should be obtained from the patient or guardian prior to preparing the medication. Tell the patient what the medication is, what it is given for, the dosage, and the route that will be used. Checking the medication three times helps prevent medication errors. The first check is comparing the medication order to the medication. The second check occurs after the medication is prepared for administration. The third check is completed immediately prior to administering the medication to the patient.

Injection equipment and supplies

The correct syringe and needle 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. A gauze pad is used to apply pressure or hold at the site after administration. An adhesive bandage should be available if there is bleeding at the site. A sharps container should be located nearby to avoid transporting contaminated needles from where the injection was administered. A biohazard container is necessary for the disposal of other potentially contaminated items. A tray for transporting prepared medications and supplies from the workstation to the patient can increase efficiency. An injection is an invasive procedure and the medical assistant could be exposed to blood and body fluids, so nonsterile gloves and other appropriate PPE as required

Selecting the needle gauge and length

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 being 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. The following chart provides basic uses for lengths and gauges. To select the appropriate needle, the medical assistant must be familiar with the viscosity of the medication, the route selected, and the location of administration. When choosing a length, also consider the size of the patient.

Checking allergy status prior to administration of medication

Ask the patient about allergies. Although a patient might not have had an allergic or adverse reaction to a medication in the past, it is always possible to develop a reaction in subsequent treatments. Alert patients to potential adverse reactions when taking medications. After administration of any medication, ask the patient to wait 10 to 15 minutes before leaving for observation of any possible adverse reactions. Anaphylaxis is the most severe form of an allergic reaction and tends to occur rapidly after the administration of a medication. The route affects the speed of reaction because medications enter the circulatory system based on absorption into the bloodstream. A medication that is administered intramuscularly absorbs more rapidly than an oral, subcutaneous, or intradermal medication

injection equipment and supplies

The correct syringe and needle 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. A gauze pad is used to apply pressure or hold at the site after administration. An adhesive bandage should be available if there is bleeding at the site. A sharps container should be located nearby to avoid transporting contaminated needles from where the injection was administered. A biohazard container is necessary for the disposal of other potentially contaminated items. A tray for transporting prepared medications and supplies from the workstation to the patient can increase efficiency. An injection is an invasive procedure and the medical assistant could be exposed to blood and body fluids, so nonsterile gloves and other appropriate PPE are required.

Needle safety

All healthcare professionals must abide by the OSHA Needlestick Safety

and Prevention Act. This means that engineering controls must be implemented to eliminate or reduce the risk of exposure to bloodborne pathogens. Easily accessible sharps containers and self-sheathing or safety needles are examples of required controls. Never recap a used

needle. Ensure that patients are prepared for the injection or ask for assistance in holding the patient still if needed to avoid accidental needle sticks

Keeping equipment sterile

Whenever invasive procedures are conducted, take precautions to maintain the sterility of devices that break the protective skin layer. Needles and syringes must be sterile. Check the expiration date of solutions before preparing the medication, and evaluate the integrity of the container. The use of alcohol swabs on a vial stopper assists in preventing the introduction of germs into the solution as well as keeping the needle sterile. Do not introduce the needle into the vial more than once. Each re-puncture into a vial dulls the needle and predisposes the equipment to contamination. Allowing solutions to run down a needle also increases the likelihood of contamination. Take care to not place the exposed needle on a tray or countertop. Although a clean needle may be recapped for protection prior to an injection using a one-handed scoop method, this should only be done if absolutely necessary because contamination by an incidental stick is possible

Selecting the needle gauge and length

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 being 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. The following chart provides basic uses for lengths and gauges. To select the appropriate needle, the medical assistant must be familiar with the viscosity of the medication, the route selected, and the location of administration. When choosing a length, also consider the size of the patient

Checking allergy status prior to administration of medication

Ask the patient about allergies. Although a patient might not have had an allergic or adverse reaction to a medication in the past, it is always possible to develop a reaction in subsequent treatments. Alert patients to potential adverse reactions when taking medications. After administration of any medication, ask the patient to wait 10 to 15 minutes before leaving for observation of any possible adverse reactions. Anaphylaxis is the most severe form of an allergic reaction and tends to occur rapidly after the administration of a medication. The route affects the speed of reaction because medications enter the circulatory system based on absorption into the bloodstream. A medication that is administered intramuscularly absorbs more rapidly than an oral, subcutaneous, or intradermal medication

Following the rights of medication administration

Incorporate several checks and balances with every medication administration to confirm the

right patient, the right dose, the right route, and other confirmatory measures are in place prior to any

medication administration. Refer to Chapter 3: Pharmacology for additional details regarding the rights of medication administration

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 parenteral administration of medications are identified in the following charts. The dorsogluteal site is no longer recommended largely due to the potential complications that can occur if the sciatic nerve is damaged

Storing medications and medication logs

Store medications according to the manufacturer's directions and in their original containers.

This can include specific instructions such as refrigerating or protecting from light. Controlled

substances identified by the Drug Enforcement Agency (DEA) must remain locked and secured. A log book and a daily count by two people are required for controlled substances kept in the office. Medication logs ensure that all medications are accounted for. They are required to be maintained for controlled substances administered to patients. In addition, when medications need to be destroyed due to expiration or other circumstances, two people should witness the process and their names should be documented in the disposal log

Immunization information

n informationVaccines are administered to provide immunity from specific diseases that lead to morbidity or

mortality. Immunizations begin as early as 1 month old with childhood vaccines and continue

through adulthood with tetanus boosters and the shingles vaccine. While vaccines prevent or reduce the symptoms of various diseases, complications, and adverse reactions are possible. Be aware of potential adverse reactions and gather a thorough vaccine history from the patient to ensure the patient is not allergic to any of the ingredients in the vaccine being administered. The current recommended vaccine schedule is available on the Centers for Disease Control and Prevention website at www.cdc.gov

IDENTIFYING AND RESPONDING TO EMERGENCY/PRIORITY SITUATIONS

It is important to be prepared, alert, and ready to respond to potential threats or emergencies in

the clinical setting. Emergencies such as choking, allergic reactions, and trauma require emergency first aid procedures. Any condition that leads to cardiac or respiratory failure mandates the rapid implementation of life-saving measures, including calling 911 and initiating CPR. Be aware of external and environmental emergencies as well. These include weather-related emergencies (tornados, hurricanes, fires) and human-related threats such as assault with deadly weapons. All employees should annually review and be knowledgeable of the emergency evacuation and response plans. In addition, if any updates are made to the plans, the employees must be notified of the revisions

Emergency action plan

The emergency action plan can include triage to deliver immediate care to patients who have life-threatening conditions. Action plans should identify when and who should contact emergency medical services during a crisis situation. Emergency equipment ( automatic external defibrillator [AED], vital sign equipment, bandages, dressings) is often needed for physical emergencies and should be readily accessible. All staff should know the location of fire extinguishers and emergency evacuation routes. In the event of an emergency situation, the medical assistant or other available health care staff should stay with the patients until a provider or emergency services personnel are available to take over and be responsible for delivering emergency care when necessary. In addition, the medical assistant is often a member of the health care team who is responsible for making sure all needed equipment and supplies are ready for the provider during an emergent situation.

STAPLE AND SUTURE REMOVAL

Under the direction of the provider, medical assistants can remove sutures or staples. Prior to

removal, a thorough inspection of the wound to approximate the edges and the absence or presence of drainage is necessary. Wounds that have crusting blood or exudate will usually need soaking with saline prior to removal of the sutures or staples. Equipment for suture removal includes stitch or suture scissors and forceps. 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. Butterfly closures can be used to provide reinforcement of the wound after the removal of the sutures or staples depending on the condition and location of the wound

ANTHROPOMETRIC MEASUREMENTS

Anthropometric measurements can play a significant role in assisting the provider with making

a diagnosis. Measuring height and weight can be a sensitive issue with patients. Be alert to these concerns and display empathy while ensuring accuracy when obtaining measurements.

Height

Height is part of a routine physical to track normal development, and monitor conditions such as scoliosis or osteoporosis, and assist in determining BMI. Patients should stand erect looking forward without shoes. The leveling bar on the wall or scale needs to sit squarely on the top of the head to get an accurate reading. If measurements are obtained in inches, the medical assistant might need to convert inches to feet and inches for charting. Measurements can also be recorded in centimeters depending on the provider’s preference. To convert height from inches to feet and inches, divide inches by 12. Example: 62 inches = 62/12 = 5 feet 2 inches

Weight

Obtaining a patient’s weight is necessary at each office visit. Medications are often determined

based on weight. BMI, predisposition to medical conditions, and the monitoring of eating disorders and weight management are among the reasons weight is obtained. Patients are often embarrassed about their weight and resistant to having it measured. Obtain weight in a private area and avoid stating the measured weight loud enough for others to hear. Completing the task in a timely, efficient manner reduces patient anxiety regarding this part of the visit. Make sure the scale is balanced and review the record to determine a baseline weight prior to asking the patient to stand on the scale. Take special precautions to protect the patient from injury. Assist the patient on and off the scale and monitor stability as needed. Weight is measured in pounds or kilograms. 1 kg = 2.2 lb To convert pounds to kilograms, divide the weight in pounds by 2.2. To convert kilograms to pounds, multiply the weight in kilograms by 2.2

Body mass index

Body mass index (BMI) is not an indicator of health or a means to deliver a diagnosis. Rather, it

is a tool to screen patients and classify results into weight categories. This classification then can be used to correlate risk factors or predisposition for conditions such as heart disease or diabetes. BMI is calculated using the following formula.

weight in kg = BMI height in m² or weight in lb × 703 = BMI height in inches² A BMI of 18.5 to 24.9 is considered normal. Results less than 18.5 classify an individual as underweight. Greater than 24.9 leads to a classification of overweight, with obesity being 30.0 and greater. The medical assistant may be responsible for calculating BMI using graphs or using a

Pediatric measurements

Pediatric measurements monitor growth. Height, weight, and head circumference are completed during a routine physical exam. If there are no concerns about growth, then the weight is typically the only anthropometric measurement obtained at each office visit. It can be challenging to measure a child’s growth patterns due to a lack of cooperation from the child. The medical assistant can need to ask a parent to hold an infant in place to get an accurate height. Another option is giving the child something to hold or distracting them while the measurements are obtained. If the child is unable to stand erect, lay the child or infant flat on a paper-covered table. Place a mark at the top of the head and at the heel of the flexed foot. Record this measurement in centimeters or inches. Weight is more accurate if the infant is able to lie down or sit on an infant scale. Infant scales measure in pounds and ounces and therefore are more accurate. Weigh infants without clothing or a diaper. Using a tape measure, measure the head circumference at the widest area, which is usually right across the eyebrows, measuring in inches or centimeters. Repeat the height and head circumference twice to confirm the results

Growth charts

Pediatric measurements are important in the physical assessment of infants and children up to 3 years of age. These measurements are plotted on a growth chart to provide a visual representation of growth. This alerts the provider to potential concerns. The growth chart also provides a tangible piece of data to have conversations with parents and guardians regarding concerns such as obesity or malnutrition.

Considerations related to age, health status, and disability

The medical assistant must be aware of normal growth and development as well as the

patient’s physical and medical status in determining the best method to obtain anthropometric

measurements. For example, an infant cannot stand on an adult scale, an adult who is unstable might need assistance to get on the scale, and some patients might need a scale that has bars for stability. Patients who have vision and hearing impairments need additional assistance in other instances. As a last resort, the medical assistant might need to record the measurements as reported by the patient or caretaker. If this is done, make a note in the chart to explain how the measurement was obtained. Regardless of the method, take care to maximize patient safety and obtain an accurate measurement.

ent models such as “pay for performance” requires a specific mindset for those delivering health care. The patient’s health is everyone’s responsibility. In organizations that practice team-based care, team members work collaboratively to provide seamless care. This allows patients to obtain the best care possible without interruptions. Everyone works at the top of their license or credential in these settings by aligning staff responsibilities to their credentials. For team-based care to be effective, many clinicians are needed to address all needs of the patient. Primary care providers include the physician, nurse practitioner, or physician assistant. Other healthcare providers include mental health specialists; physical, occupational, and speech therapists; pharmacists; nutritionists; and dentists. Patients who have chronic conditions are usually assigned a nurse case manager to follow them throughout their disease. Support staff (medical assistants, administrative staff members) also play a key role in team-based care settings.

Specific roles of team members

The primary care provider (PCP) is the first provider the patient seeks care from. One of the PCP’s main goals is to coordinate preventative health care services (regular check-ups, screening, tests, immunizations, health coaching). PCPs can be family practitioners, internal medicine or doctors of osteopathy (DO), or pediatricians. Pediatricians offer preventative care services and treat common pediatric conditions such as viral infections or minor injuries.

A specialist is a provider that diagnoses and treats conditions that require a specific area of

expertise and knowledge. Primary care providers may refer patients to a specialist to diagnose or treat a specific short-term condition. For chronic diseases, patients can work with specialists for an ongoing period of time.

Physician assistants (PAs) have similar training to physicians and are licensed to practice

medicine as long as they are supervised by a medical doctor (MD). PAs can conduct physical exams, provide preventative care, prescribe diagnostic tests, assist with surgical procedures, diagnose illnesses, and prescribe medicine.

Advanced practice nurses have more education and experience than RNs and can usually perform the same tasks as physician assistants. Clinical nurse specialists, nurse anesthetists, nurse practitioners (NP), and nurse midwives are common advanced practice nurses.

With a nationwide shortage of physicians going into primary care, PAs and NPs is a solution that is more cost-efficient than physicians.

Registered nurses (RNs) are licensed by individual states and have an associate's or bachelor’s

degree in nursing. RNs usually oversee the case management of patients who have complex chronic conditions. They also coach patients about their overall health.

Practical nurses (PNs) are sometimes referred to as vocational nurses and are also licensed by individual states. PNs usually train for approximately 1 year at a community college or vocational school, receiving a diploma or associate degree. These healthcare professionals often triage phone calls, administer medications, and assist with other clinical duties in the clinical setting.

Pharmacists prepare and dispense medications prescribed by authorized providers. They must be knowledgeable of individual and various combinations of medicines to be able to educate patients on their use and answer questions about side effects. Using a pharmacist to implement medication therapy management is relatively new to ambulatory care

Dentists diagnose and treat issues relating to the teeth and mouth. Dentists also educate patients on ways to prevent problems with oral health. Many community health centers include oral health services to patients.

Occupational therapists assist and educate patients on how to perform everyday tasks after a

physical, mental, or developmental disability has occurred. Physical therapists

assess a patient’s pain, strength, and mobility and then develop a treatment

plan to improve any areas of concern.

Speech therapists or speech-language pathologists work with patients who have problems with speech and swallowing due to an injury, cancer, or stroke. They focus on helping a person work toward improving, regaining, and maintaining the ability to communicate, chew, and swallow. Some clinics offer rehabilitation services. Having therapy services within the clinic is an added convenience for many patients and improves the communication process between providers and therapists. Psychiatrists are MDs who diagnose, prescribe medications and treat mental, behavioral, and emotional disorders.

Psychologists are not MDs but have a doctor of psychology (PsyD) or a doctor of philosophy degree (Ph.D.). They work with patients who are experiencing mental health challenges, especially during times of stress or emotional turmoil.

Social workers assist patients and families in times of transition or crisis. They assist patients in a clinical or hospital setting with physical, emotional, and financial issues related to an illness or injury. Social workers often coordinate additional services (transportation, housing, access to meals, financial resources, long-term, hospice services).

Providers on the mental health team that work in the PCMH or ACO usually contract with the

facility to work a specific number of hours per week. Clinics with a large census can include a full-time social worker as part of their permanent staff

registered dietitian nutritionist (RDN) is an expert in diet and nutrition. RDNs educate patients

on the connection between chronic disease and poor nutrition, assist with menu planning, and help low-income patients obtain healthier foods at lower prices.

Some patients rely on religion or spirituality to cope with an illness or injury. Priests, ministers, and rabbis are some clergy members who often provide patients with this spiritual support.

Support Staff

Administrative and clinical staff professionals are also key players in providing the best possible

experience for healthcare consumers. Scheduling appointments, answering phones, greeting

patients, maintaining medical records, assisting providers during exams/procedures, performing measurements, processing billing, completing insurance forms, performing laboratory or other diagnostic services, and managing financial records are some of the responsibilities of the administrative and clinical support staff in a medical office. Here are a few examples of these jobs.

⦁Clinic Coordinator

⦁Medical administrative assistant

⦁Clinical medical assistant

⦁Medical records specialist

⦁Medical billing specialist

⦁Financial counselor

⦁Scheduler

Patients and family members

The role of the patient and family members is more active in patient-family-centered health care than in the traditional delivery of health care. The wants and needs of the patient and family are the focus areas in this type of delivery. All parties have a say in how the patient receives treatment, what those treatments will be, the desired outcome, and education and counseling to achieve these goals. The key to achieving full participation of patients and their families is good communication. When this is successful, patients report improved symptoms and overall better outcomes. When patients feel like they are in partnership with their provider, they have increased satisfaction with their care. Fewer hospitalizations, less testing, and fewer treatments are also achieved with successful patient-family-centered health care. As a result, healthcare costs are also decreased

Institute for Health Care Improvement Triple Aim

The Institute for Health Care Improvement (IHI) has a rubric for health care transformation. The

three goals are:

⦁Improving the experience of care.

⦁Improving the health of populations.

⦁ Reducing costs of health care.

Methods for meeting these goals are the implementation of either a PCMH or ACO. These models both use the team-based or patient-family centered care model. For the IHI Triple Aim to be met, all three goals must be accomplished

Health care models that practice team-based care

The enactment of the Affordable Care Act emphasizes the need for team-based medicine. The three main goals of ACA were to:

⦁Expand health insurance coverage.

⦁Shift the focus of health care delivery system from treatment to prevention.

⦁Reduce costs and improve the efficiency of health care

Medical law and ethics

LEGAL AND REGULATORY REQUIREMENTS

To comply with legal and regulatory requirements, the medical assistant must understand the legal system. The following section provides some basic terminology used in the legal system

Legal fundamentals

Criminal law

addresses the rules and statutes that define wrongdoings against the community as a

whole. Crimes can be classified as misdemeanors or felonies. A misdemeanor is considered less serious than a felony and carries a lesser penalty, usually a fine or imprisonment for less than a year. Examples of misdemeanors include reckless driving and discharging a firearm in city limits. A felony is more serious than a misdemeanor and constitutes a stiffer penalty, usually, imprisonment greater than 1 year, and, in extreme cases such as murder, can result in a death sentence. An assault is an instance in which someone threatens to cause harm to an individual. battery is intentional touching or the use of force in a harmful manner, without the individual’s consent. A plaintiff is an individual that files a lawsuit to initiate legal action. A

defendant is a person that is being sued or accused of a crime in a court of law. A

subpoena is a written order that commands someone to appear in court to give evidence. Oftentimes, attorneys will depose a defendant or a witness before a case is brought to trial. A

deposition is a formal statement in which the individual who is being deposed promises, to tell the truth. These statements are often used during a court proceeding, especially when the defendant or witness changes their view of what occurred from the time of the deposition to the day of the hearing

Civil law is applied most often in medical malpractice cases. Civil law governs the private rights of individuals, corporations, and government bodies and includes cases involving

contracts, family matters, and property issues. A contract is a legally binding agreement between two or more individuals or entities to do something. For example, a contractor agrees to provide services in exchange for a fee. In order for a contract to be valid, it must contain the following four elements.

⦁ Mutual assent: An agreement by all parties to 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 legal

When a party fails to hold up their part of a contract, they may be sued for

breach of contract. This is why medical consent forms often include risks associated with the procedure and unsatisfactory disclosure statements, which state that the provider does not guarantee satisfactory results. This is common for cosmetic procedures. In civil law cases, there are usually no fines or imprisonment. However, plaintiffs may receive a monetary award for injuries sustained as a result of a particular incident. In a medical negligence case, the plaintiff may receive compensation for medical expenses, lost wages, and the pain and

suffering associated with the negligence.

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. In general, administrative agencies are responsible for protecting the civil rights, privacy, and safety of their citizens. The Health Insurance Portability and Accountability Act (HIPAA) came out of administrative law. The HIPAA Privacy Rule is designed to protect the patient’s personal and medical information. Administrative judges at the state or federal level usually oversee these cases.

The legal system is a guide that is used in health care to ensure patients’ and providers’ rights are protected. When the legal system is violated, litigation can occur. Litigation is a lawsuit that will include a defendant and a plaintiff. Patients, providers, and healthcare workers need to understand their legal rights

Federal laws that affect medical practices

Medical assistants should be familiar with laws that affect the medical community. Here are some of the most common laws that affect medical practices.

Affordable Care Act (ACA): The ACA was put in place to reform the health care system by providing more Americans with affordable, quality health insurance to ultimately curb the growth in health care spending in the United States. Future modifications or replacement of this act will likely include prevention, wellness, and collaborative care strategies.

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. HIPAA applies to protected health information, whether electronic, written, or oral.

Controlled Substances Act (CSA): CSA is a federal policy that regulates the manufacture and

distribution of controlled substances. Controlled substances can include narcotics, depressants, and stimulants. The CSA classifies medications into five schedules, or classifications, based on the likelihood for abuse, status in international treaties, and any medical benefits the substance might provide.

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.

Equal pay act: The Equal Pay Act mandates the same pay for all people who do substantially equal work regardless of sex.

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.

The 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

State laws that affect medical practices

State medical practice acts and laws that affect what responsibilities may be delegated to a medical assistant are different for each state. In addition, other providers (nurse practitioners, chiropractors) have their own state medical practice acts. Be aware of the tasks that can legally be delegated to a medical assistant based on the laws of the state in which the practice is located. Some states have a clearly defined scope of practice for medical assistants. However, the majority of states do not specifically mention medical assistants but instead, use the broad term “unlicensed agents” or something similar. Some states require a medical assistant to be certified or registered to administer medications. General procedures that fall in the recognized scope of practice for a medical assistant can include the following.

⦁ Schedule patients for procedures and treatments within the medical office or outside

the specialty clinic.

⦁ Greet patients and assist them with registration processes.

⦁ Prepare patients for provider exams by positioning and educating them regarding the procedure.

⦁ Prepare examination rooms and necessary equipment and supplies.

⦁ Obtain and document vital signs.

⦁ Obtain and document patient history using medical terminology.

⦁ Provide therapeutic communication to the patient, and accurately convey clinical information

from the provider to the patient.

⦁Perform basic wound care (dressing changes, retrieving wound cultures).

⦁ Remove superficial sutures or staples.

⦁Operate approved diagnostic equipment without test interpretation.

• Provide patient education and instructions for procedures.

⦁ Administer medications orally, topically, sublingually, vaginally, rectally, and by injection (as

permitted by supervising provider).

⦁ Be certified to perform CPR and provide first aid in an emergency.

⦁ Perform venipuncture and capillary blood collection.

⦁ Perform simple laboratory and screening tests,

such as urinalysis.

⦁ Conduct filing, bookkeeping, and inventory.

⦁ Process insurance claims and perform basic transcription for medical records dictation.

⦁ If approved by the provider, call in prescriptions or refills to the pharmacy.

Standard of care

Healthcare professionals have a standard of care they are expected to follow while performing

professional duties. Standard of care is the degree of care or competence that one is expected to exercise in a particular circumstance or role. Negligence is the failure to do something that a

reasonably prudent individual would do under similar circumstances. Negligence cases use the standard of care to decide whether a provider met the standard of care necessary to adequately perform their role. As part of the standard of care, healthcare workers must not stray from their scope of practice. Medical assistants that perform tasks outside their scope of practice breach the standard of care. An expert witness, which is usually someone who has similar training and credentials as the party being sued, is often used during negligence cases to establish what the standard of care is for a particular situation and whether that standard was met.

Tort law

A 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 negligent.

An intentional tort is a deliberate act that violates the rights of another. Examples of intentional torts include assault, battery, defamation of character, invasion of privacy, and administering an injection without the consent of the patient. The plaintiff in an intentional tort case does not need to prove the defendant intended to cause harm, just that the willful act of the defendant caused harm to the plaintiff. Defamation of character is hurting someone’s reputation. Slander is verbal defamation, while libel is written defamation. Invasion of privacy is an intrusion into the personal life of another individual without just cause. Prying into a patient’s medical record or sharing information about a patient to another party without their consent are examples of invasion of privacy. Negligence is a common tort in malpractice cases. Res ipsa loquitur and respondeat superior are two Latin terms that can be used to describe certain aspects of negligence. Res ipsa loquitur literally means “it speaks for itself.” In other words, the negligence is obvious. In these cases, the burden of proof falls on the defendants to prove they were not negligent. An example of a res ipsa loquitur case would be finding an instrument inside the patient following a surgical procedure or a patient sustaining burns while lying on a heating blanket. Respondeat superior is a doctrine that states that employers are responsible for the actions of their employees when the actions are performed within the constraints of their position. This doctrine came from the common law “master-servant rule.” Negligent torts are unintentional. To prove negligence, the plaintiff must prove the following, often referred to as the “Four D’s of Negligence.”

⦁ A duty existed.

⦁ There was a dereliction of duty.

⦁ The misconduct of the defendant was the direct cause of the injury.

⦁ Damages (usually substantial) occurred as a result of the misconduct

Violation of state medical practice acts can result in the provider or health care worker being

accused of the following.

⦁ Malfeasance is the performance of an unlawful, wrongful act; for example, performing a procedure on the wrong patient.

⦁ Misfeasance is the performance of a lawful action in an illegal or improper manner; for example,

performing the procedure on the correct patient, but doing so incorrectly.

⦁ Negligence is the failure to do something that a reasonable person of ordinary prudence would do in a certain situation, or the doing of something that such a person would not do.

⦁ Nonfeasance is failure to perform a task, duty, or undertaking that one has agreed to perform or has a legal duty to perform; for example, waiting to treat a patient until it is too late

Types of consent

In the clinical setting, there are two types of consent: implied and informed.

Informed consent is a clear and voluntary indication of preference or choice, usually oral or written, and freely given in circumstances where the available options and their consequences have been made clear. An example is signing consent forms prior to a procedure. Implied consent is a voluntary agreement with an action proposed by another. An example is patients rolling up their sleeves to give blood. Consent is an act of reason. The person giving consent must be of sufficient mental capacity and be in possession of all essential information to give valid consent. Consent must be free of force or fraud. Fraudulent actions relate to actions that purposely intend to deceive someone.

PROFESSIONAL CODES OF ETHICS

Ethics is the discipline concerned with what is morally good and bad, or right and wrong. Ethics

can be debated depending on a person’s beliefs or way of thinking. An individual’s personal morals and religious upbringing often contribute to their personal ethics. Professional ethics are a set of accepted behaviors and values that a person is expected to possess in a particular organization or profession.

Hippocratic Oath

Medical assistants work under the direct supervision of providers who take the Hippocratic

Oath. Many doctors recite this oath during their graduation ceremony from medical school. The

Hippocratic Oath sets the framework for ethical principles related to the practice of medicine.

Medical assisting code of ethics

Each credentialing organization has a code of ethics for the professionals they certify. The code of ethics is a pledge to guide members’ behavior. Although organizations have different sets of ethics, they all are committed to abiding by all laws

NHA Code of Ethics

As a certified professional through the NHA, I have a duty to:

⦁ Use my best efforts for the betterment of society, the profession, and the members of

the profession.

⦁ Uphold the standards of professionalism and be honest in all professional interactions.

⦁ Continue to learn, apply, and advance scientific and practical knowledge and skills; stay up to date on the latest research and its practical application.

⦁ Participate in activities contributing to the improvement of personal health, our society, and the

betterment of the allied health industry.

⦁ Continuously act in the best interests of the general public.

⦁ Protect and respect the dignity and privacy of all patients

PERSONAL OR RELIGIOUS BELIEFS AND VALUES, AND UNBIASED CARE

Patients may have religious and personal beliefs and values that affect their decisions surrounding health care. Some current ethical issues surrounding health care include end-of-life care, resuscitation orders, euthanasia, abortion, birth control, and genetic testing. There are many areas of health care that can be tied to a person’s religious or personal beliefs. Regardless of a patient’s personal or religious beliefs, they must receive standard care.

In some cases, a medical assistant’s religious or personal beliefs may be violated as a result of

performing duties associated with employment. Examples include assisting same-sex couples with infertility treatments or performing phlebotomy procedures at a termination or abortion clinic. It is important to know the responsibilities associated with a position prior to employment to avoid being placed in an ethical or moral dilemma. Whether medical assistants agree with a patient’s or coworker’s position on an ethical issue does not give them the right to ridicule or treat that individual differently

HEALTHCARE PROXIES AND AGENTS

A health care proxy or agent is the person assigned to make health care decisions for the patient if they are incapacitated. Determining the health care proxy or agent is an important decision when planning for the future. Once a documented proxy is in place, be sure the patient’s family and providers have a copy of the documentation

INFECTION CONTROL

The employer has the responsibility to ensure a safe work environment. Several

Occupational Safety and Health Administration (OSHA) measures contribute to employee safety in a healthcare setting, and infection control is one of them. Along with OSHA, the Centers for Disease Control and Prevention (CDC) provides recommendations to keep patients and workers safe according to established best practices. The CDC introduced universal precautions in the 1980s in response to the growing number of the human immunodeficiency virus (HIV) and hepatitis B virus (HBV) cases. This has evolved into the current practice of standard precautions. In 2001, OSHA implemented the Bloodborne Pathogens Standard in order to provide further protection to patients and workers exposed to disease-causing micro-organisms. OSHA requires all healthcare facilities to develop and annually review an effective exposure control plan specific to the organization. At a minimum, the plan must consist of the following: protections in place for jobs with exposure to infectious material, use of personal protective equipment (PPE), action plans when an exposure incident occurs, labeling of hazardous substances, immunizations offered, record-keeping, and training for employees related to the Bloodborne Pathogen Standards. The use of standard precautions greatly reduces the number of healthcare-associated infections (HA)

Six links in the chain of infection

In order for the transmission of a pathogen to occur, the following links must be connected.

⦁ Infectious agent

⦁ Reservoir

⦁ Portal of exit

⦁ Mode of transmission

⦁ Portal of entry

⦁ Susceptible host

Effective infection control consists of breaking this chain, thus preventing the continuation of the cycle

Disease transmission and prevention

In order for the transmission of disease to occur, there must be a pathogen or infectious agent present. These disease-causing micro-organisms are most often in the form of viruses, bacteria, fungi, or protozoa. An environment conducive to pathogen survival is known as a reservoir. In a clinical setting, the reservoir is often the patient but can also be an inanimate object such as a piece of medical equipment. The human body makes an ideal reservoir for microbial growth because of the presence of nutrients, moisture, ideal temperature, and pH levels. The portal of exit is the passageway that the pathogen uses to exit the reservoir. This can be the infected body fluids of an individual in a patient care setting. Once the pathogen exits the reservoir, a mode of transmission is necessary in order for the cycle to continue. Direct transmission takes place when there is contact with the infected person or body fluid that is carrying the pathogen. Indirect transmissions occur when there is an intermediate step between the portal of exit and the portal of entry. Either fomites or vectors play a role in indirect transmission. Once the pathogen has a means of transmission, it will need a new portal of entry to continue the infectious cycle. Pathogens often enter a host via an open wound or through the mouth, nose, eye, intestines, urinary tract, or reproductive system. The final step in the cycle is the presence of a susceptible host. Several variables make the human body—especially of a compromised patient—the ideal susceptible host. Factors such as overall health, age, and the condition of a person’s immune system all affect the chances of them becoming a host for disease transmission. If one of the links in the infection cycle is broken, the transmission is halted. It is the responsibility of all healthcare professionals to take the necessary steps to break this cycle. Each pathogen has specific routes in which transmissions can occur. Clinical facilities issue a variety of isolation practices according to the identified pathogen. If one is not identified, the most restrictive isolation is often used.

Personal protective equipment

Employers must provide PPE to all employees when there is a potential for exposure to blood or body fluids. It is the employee’s responsibility to use the PPE when contact with blood or body fluids is anticipated. Examples of PPE include gloves, goggles, face shields, and gowns. If an employee is allergic to latex or the powder used in the gloves provided, the employer must provide hypoallergenic or powder-free gloves at no expense to the employee.

Safety Data Sheets

OSHA requires that all employers provide SDSs to their employees. Any time a new chemical is

brought into the work environment, SDS information must accompany the chemical. Medical

assistants work with a variety of solutions ranging from mild detergents to toxic chemicals. The following information must be included on the SDS in order to communicate the hazards and actions necessary if exposure to the chemical occurs.

⦁Identification: Product identifier, manufacturer information, recommended use, restrictions on use

⦁Hazard identification: All hazards related to the chemical including label requirements

⦁Composition/ingredients: Chemical ingredients

⦁First-aid measures: Symptoms and effects from exposure including treatment necessary

⦁Fire-fighting measures: Appropriate extinguishing methods and chemical hazards from fire

⦁Accidental release measures: Emergency procedures, PPE, containment, and cleanup

⦁ Handling and storage: Safe handling and appropriate storage requirements

⦁Exposure controls/personal protection: Recommended exposure limits and PPE necessary

⦁Physical and chemical properties: Chemical characteristics

⦁Stability and reactivity: Chemical stability and potential reactions

⦁Toxicological information: Measures of toxicity, acute and chronic effects, routes of exposure;

also needs to include ecological, disposal, transport, and regulatory information regarding

the chemical

⦁ Other information: Additional information including the last revision

Exposure control plan for a biological or chemical spill

It is the responsibility of the employer to have an exposure control plan in place and available

for all employees. The plan should be reviewed with each employee upon hiring, annually, and

after any updates. The exposure control plan covers all scenarios regarding emergency procedures specific to their practice. Included in these plans should be the steps to be followed in the event of a biological or chemical emergency. Medical professionals often recognize a looming community emergency before the public does. Whether it is the rapid transmission of an infectious disease or the response to an acute traumatic event, medical staff must be ready to respond accordingly. It is important for the medical assistant to know which health officials to notify regarding the incident. Local emergency management agencies along with various governmental agencies might need to collaborate in order to provide the best care and communication for the public.

DISINFECTION/SANITIZATION

Infection control includes not only the patient and the employee, but also ensuring that the

equipment and supplies used in the clinical setting are free from disease-causing micro-organisms. The type of cleaning depends on the piece of equipment and the type of procedure it will be used in. Surgical instruments are handled differently than patient assessment tools found in an exam room

Sanitization

Sanitization is often the first step in assuring that a piece of medical equipment is as clean as

possible. This process reduces the number of microbes to a lower level so that they are ready to undergo the sterilization or disinfection process. Sanitization is especially helpful if there is visible debris present on the equipment. Gloves must be worn during this process. If there are sharps needing sanitization, wear thick utility gloves to avoid injury. Follow the manufacturer’s instructions regarding water temperatures and types of detergent to use during this process. It is important to keep the work area separated into dirty and clean areas to avoid cross-contamination of equipment. For facilities that work with very delicate instruments, ultrasonic sanitization is used to avoid damage to the equipment. Rather than using friction to remove the debris, the sound waves loosen the debris so the object is free from excess material going into the disinfection or sterilization phase. Ultrasonic sanitization also reduces the risk of sharps exposure for the healthcare worker

Disinfection

Disinfection is the process of destroying pathogens on a surface. Even though it might not destroy all of the microbial spores, it greatly reduces the spread of infection by destroying or limiting microbial activity. The solutions used in disinfection are effective when used correctly. The process can often require lengthy submissions in the chemical. Glutaraldehyde is a common disinfectant used in the clinical setting but usually requires a long submersion time in order to be fully effective. A cheaper and more effective alternative is a 1:10 bleach solution. Chemical disinfectants cannot be used on patients and are reserved for medical supplies, equipment, and surroundings

DISPOSAL OF BIOHAZARDOUS MATERIALS

OSHA also requires the disposal of infectious and hazardous waste to be handled according to safety standards. The use of PPE and Safety Data Sheets (SDSs) provides the health care worker with the tools and resources to maintain a safe clinical work environment. The proper identification and disposal of contaminated material is another step in preventing the spread of infectious material.

OSHA guidelines for disposal of biohazardous materials

Any 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. Any item that has sharp edges or blades, such as a scalpel, should also be placed in a sharps container. Sharps containers must be made of puncture-proof, leak-proof material and be labeled with the biohazard symbol. Gloves, gauze, bandages, and other items that do not have sharp edges or contain needles should be placed in a biohazard bag, which is leak-proof and labeled with the biohazard symbol. When a sharps container is two-thirds full, the container should be sealed and placed in the designated area

for disposal. All biohazard waste must be identified with the biohazard symbol and must be contained. All bags used to collect infectious material must be made of impermeable polyethylene or polypropylene material. A lid must be present on all boxes or receptacles and replaced after each use. A waste management company is often used for the pick-up and disposal of biohazard material from medical facilities. These agencies also must abide by OSHA standards regarding biohazard material handling and disposal.

Testing and laboratory procedures

SPIROMETRY/PULMONARY FUNCTION TESTS (ELECTRONIC, MANUAL)

Noninvasive lung functioning tests can be used in the ambulatory care setting. The medical

assistant is responsible for preparing the patient for the procedure, performing and documenting the procedure, and providing results to the provider for interpretation. Two of the most common noninvasive methods are spirometry and peak flow meter testing.

Peak flow testing

Instruct the patient about the proper way to perform peak flow testing. This test can be used to

monitor lung function in the home, especially for patients who have chronic respiratory diseases such as asthma. The peak flow meter measures the forced expiratory volume, which indicates the effectiveness of airflow out of the lungs. Peak flow meters can vary in size and shape depending on the manufacturer, but most are inexpensive. patient’s instructions are the same across models.

⦁ Wear nonrestrictive clothing.

⦁ Begin with the marker at the bottom of the scale on the meter.

⦁In an upright sitting or standing position, take a deep breath and forcefully blow out of the mouth, which is secure around the mouthpiece of the machine.

⦁ Record the number where the marker is located at the end of the test.

⦁ Repeat the test two to three times and record the results.

Assist the patient by providing instructions, demonstrating the technique, and allowing the patient to practice several times before completing the procedure

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. The medical assistant

will likely apply a clip to the patient’s nose to avoid nose-breathing during the procedure.

The patient should lift the chin slightly and extend the neck a little during the test to reduce

breathing resistance. Patients require additional pretest preparation, which includes no large meals 2 hr before the test, no smoking 1 hr before the test, and discontinuing the use of bronchodilators or other breathing therapies (inhalers, nebulizers) for at least 6 hr before the test.

VISION AND HEARING TESTING

Screening tests are frequently conducted in ambulatory care and provide guidance for treatments or referrals. Vision and hearing screenings are affordable, as well as easily and efficiently conducted

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 testing

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. The level at which the patient can read the smallest printing clearly is the result

Distance vision testing

Distance vision is easily tested by using a distance vision acuity chart to evaluate for myopia.

Patients stand 20 feet from a chart at eye level and identify letters, shapes, or the direction

an “E” is pointing. The eyes test separately and together, but the patient can wear corrective

lenses during the test. The line at which the patient can clearly see the letters or pictures

is the result. The patient can miss one item and still pass that line. Vision is recorded as a

fraction, with 20/20 representing normal vision.

Color vision testing

Males are more commonly affected by color blindness. The most

common type of color blindness is a red-green deficiency. Screening

is done by testing the patient on 11 plates within an Ishihara book. If

the patient misses four or more, there might be a color deficiency and further testing is warranted

Visual field testing

Also known as perimetry testing, visual field testing detects eye diseases such as glaucoma. Instruct the patient to look straight ahead and respond to instructions. In an automated test, patients respond to seeing lights flash. In a manual test, patients identify

when they can see hands or fingers in their peripheral vision

Hearing tests performed in ambulatory care

Tympanometry

Tympanometry records the movement of the tympanic membrane, which can be affected by increased pressure in the middle ear. Using a small earbud, eardrum movement can be measured by changing the amount of air pressure applied. This test is valuable for determining the presence of fluid and potential infections in the middle ear. A normal tympanogram produces a peak on the graph, whereas an abnormal tympanogram will produce a flat line.

Speech, tone, and word recognition information

Medical assistants can perform audiometry if patients (especially children) can respond to directions by pushing a button or raising a hand to acknowledge when various tones are heard through headphones. The level of hearing is documented in decibels and the frequency in hertz. An adult who has normal hearing should be able to hear tones at 25 decibels, and a child should be able to hear at 15 decibels. Tuning forks are used to determine the patient’s ability to hear tones transmitted through air and bone conduction. The vibrating tuning fork is placed on top of the head or on the mastoid process to test hearing.

Phlebotomy

PREPARE SITE FOR 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. It is helpful to have the patient make a fist with the

opposite hand and place it behind the elbow of the arm being used for the procedure. This ensures the arm will stay straight and motionless during the procedure.

The seated patient should have both feet flat on the floor and sit up with good posture.

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. This will require the remaining supplies to be set up on the opposite side of the dominant hand. Whenever possible, place the sharps container on the dominant side as well. This allows the needle to be disposed of properly without the need for crossing the contaminated needle across the body. Always engage needle safety devices when disposing of a needle in the sharps container

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, and do not touch the site after cleansing. Do not blow on the area or wave your hands over it in an attempt to dry the alcohol faster, as this recontaminates the skin

DETERMINE VENIPUNCTURE SITE ACCESSIBILITY

It is important to select the safest site for venipuncture (according to patient's age and condition) that has the greatest likelihood of successful blood collection. Methods of selection include warming the site to increase blood flow and the use of a tourniquet, palpation, or infrared vein scanner.

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. Patients 6 months to 2 years of age typically require capillary samples obtained through a finger stick. For more extensive testing, traditional venipuncture can be necessary. For patients 2 years and older, a regular venipuncture is easily accessible and considered routine

Site Restrictions

During site selection, check with the patient regarding possible medical restrictions due to

fistulas, ports, or mastectomy. Each of these medical conditions can require specific blood draw procedures to prevent complications and obtain the best specimen for blood testing. Guidance for phlebotomy procedures should come from the provider and the laboratory that will perform the tests. Exercise caution with patients who have these medical conditions and proceed only within your scope of practice and experience level.

Vein anatomy

The preferred sites for venipuncture procedures performed

by a medical assistant are the median cubital vein, cephalic vein, and basilic vein. If these veins within the antecubital space are inaccessible, the hand, wrist, and foot are also options. Blood draws from the foot should only be performed under the supervision of a physician due to the risk of deep vein thrombosis (DVT)

Skin integrity and venous sufficiency

Older adult patients have concerns due to physiological changes including muscular atrophy, which changes the integrity of the skin; veins that have lost their elasticity; and venous insufficiency. With the loss of venous sufficiency, veins are prone to roll. When veins lose elasticity, they are fragile and easily damaged by venipuncture

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. This method can be useful for infant and adult patients. Capillary blood is a mixture of blood from arterioles, venules, capillaries, and intracellular and interstitial fluids. Due to this mixed composition, not all testing should be performed using capillary blood

Capillary puncture supplies

• Nonsterile gloves

⦁Automatic retractable lancets

⦁Disinfectant pads, such as 70% isopropyl alcohol

⦁Clean gauze pads

⦁Bandage wraps

⦁Micropipette

⦁Blood collection device appropriate for the test

• Small glass tube (capillary tube)

• Microcollection tube

• Glass microscope slide

• Reagent strip

• Screening card or paper

• Plastic testing cartridge or cassette

⦁Capillary tube sealer (when capillary tubes are used)

⦁Biohazard sharps container

Location of capillary punctures for adults and infants

The preferred puncture site for obtaining a capillary puncture in adults and children is the middle or ring finger of the non-dominant hand. Perform the puncture slightly off-center, avoiding the central fleshy part of the fingertip, fingernail, and nail bed. Perform infant capillary puncture on the outer edge of the underside of the heel

Preparing the site

For the procedure to be successful, the capillaries must have good blood flow. If the patient’s hands are cold, the capillaries are somewhat constricted and it can be difficult to collect enough blood. Warm the patient’s hands prior to the procedure by having the patient rub them together, run them under warm water, or sit on them for a few minutes. Prep the skin with a 70% isopropyl alcohol pad, and allow the site to air dry completely

Performing the puncture

Hold the patient’s finger between your thumb and forefinger firmly but gently. Hold the lancet

device in the dominant hand and at a right angle to the desired puncture site on the patient’s

finger. Activate the spring or trigger system on the lancet, and discard the used lancet into a sharps container. Always wipe away the first drop of blood to appear after the puncture because of its contamination with tissue fluids. Collect blood. If the blood is slow to flow, gentle pressure may be applied to the patient’s finger; avoid milking the finger. Once the specimen has been collected, place a clean gauze pad over the puncture site and ask the patient to apply pressure to the area. Properly handle the collection container (for example, inserting the capillary tube into the clay tray to seal the end and avoid losing the specimen). Once the specimen and container are intact, remove the gauze from the patient’s finger to assess hemostasis. If blood flow has slowed or stopped, a bandage may be applied. If blood flow is still considerable, apply additional gauze and pressure. For excessive blood flow from the puncture site, elevate the arm over the level of the heart to aid in hemostasis

Order of draw for microcapillary tubes

The recommended order of draw for capillary blood collection is different from blood specimens drawn by venipuncture. The Clinical and Laboratory Standards Institute recommends the following order of draw for skin puncture.

⦁Blood gases

⦁EDTA tubes

⦁Other additive tubes

⦁Serum tubes

VERIFY ORDER DETAILS

Obtaining the provider’s order for laboratory testing is the vital first step to performing any

phlebotomy procedure. Never perform a procedure without a provider’s order. Verify the order

to determine what tests will be run and the identity of the patient before any other part of the

procedure begins Correct interpretation of medical abbreviations is essential to the process of order verification. Lab tests, as well as proper blood collection tubes for the ordered tests, are typically expressed in abbreviations. Review the medical terminology and pharmacology modules for some of the most common abbreviations used in the laboratory setting

Review order and lab manual for preparation, collection, handling, and storage instructions

Upon receiving the provider’s order, review the order for completion of all required items. Verify

accuracy, requested tests, test requirements, and reporting before beginning the procedure.

Some of the required items include the following.

⦁Ordering provider

⦁Test and test code (unique to each lab, usually on the requisition or in the laboratory reference manual)

⦁ Diagnosis code that correlates with the tests being ordered (ICD-10)

⦁Special specimen requirements, such as

fasting

⦁Patient demographics

⦁ Insurance or other billing information

If there is any question regarding specimen handling requirements or the tube color for each test,

consult the facility-specific laboratory reference manual. The laboratory reference manual provides all information required for testing (how many and what color tube must be drawn; test code; whether the tube is to be centrifuged, frozen, or if it is light-sensitive)

Procedures for collecting special testing samples

There are some blood tests that require specific timing, specific patient preparation, or particular handling of the blood specimens. If the provider has ordered a specimen collection at a specific time, the medical assistant is responsible for making sure that the phlebotomy procedure and specimen collection are performed at that time. Timed specimens are crucial for therapeutic drug level monitoring to confirm the patient’s medication dosage and compliance. Blood cultures require specific preparation of the skin, as well as multiple tubes and specific specimen labeling. Failure to adhere to any of these requirements will render a specimen improper for testing or call into question the test results. Consult the laboratory reference manual if performing a blood draw for an unfamiliar test.

Consider all preanalytical factors

There are several variables to consider when performing a blood collection procedure. Some of these factors are basal state, fasting status, and the condition of the venipuncture

site. If the veins are sclerotic or the skin is scarred, evaluate an alternative location. Stress can cause an elevation in white blood cells, a decrease in iron levels, and abnormal hormone levels, among a few possible complications. Other considerations include menstrual cycle,

edema, current medications, infections, vomiting, and pregnancy. Hemoconcentration can also occur if the tourniquet is left on the patient longer than the recommended 60 seconds

Complete lab requisition form and prepare labels for tubes

It is crucial to accurately complete the lab requisition and correctly label specimen containers.

Missing or inaccurate information on the laboratory requisition or improper specimen labeling

can lead to excessive blood collection, which could be harmful to the patient’s health. Accurate

lab requisition and labeling help minimize costly and dangerous errors that result in the wrong

diagnosis and treatment.

Verify the following information against the requisition every time with every phlebotomy

procedure to minimize errors and ensure proper collection and testing of specimens.

⦁Provider’s order

⦁Patient’s identity

⦁Labeling of the specimens

⦁Identification number of the specimens

Identification of the patient

Always introduce yourself to the patient and confirm the purpose for the blood collection procedure. In this conversation, verify the patient’s identity by confirming the patient’s name, date of birth, and any other demographic information needed. Presenting a calm, professional demeanor can alleviate any fear or anxiety the patient might be feeling regarding the blood draw procedure. This also demonstrates competency and professionalism, which are key attributes of a medical assistant

Verify the patient followed laboratory preparation instructions

Often there are specific instructions or preparations that need to take place prior to collecting a

blood specimen. These are important for the accuracy of the testing values. For example, patients should fast for the completion of a lipid panel. If the patient just ate a meal prior to having blood drawn, the test values would likely detect fats from the food and the results would indicate elevated lipid levels. Therefore, verify that all specimen guidelines were followed prior to all phlebotomy draws

Test Preparation

⦁Verify whether the test requires fasting. If so, ask the patient when the last time she ate or drank anything other than water and regular medications.

⦁If testing for drug levels, ask the patient when he lasts took any medication and the names and dosages of the medications

Question patient about anxiety and comfort level

Approach each patient with a pleasant, warm demeanor. Some patients have little or no issue with the process of blood collection. Other patients have a great deal of anxiety when having blood drawn. In addition to performing the procedure correctly, it is important to make patients as comfortable as possible and be sensitive to their needs. Always question patients about previous blood draws and what their reactions have been. Be prepared for a possible adverse reaction to a phlebotomy procedure, including the vasovagal response. Throughout the blood collection procedure, check the patient’s response. This varies from casual conversation to specifically inquiring how the patient is tolerating the procedure. Be sensitive to verbal and nonverbal communication. If the patient is in obvious distress, stop the procedure and alert the provider

Explain the procedure

The process of blood collection can be distressing to patients, particularly if they have had

a negative experience in the past. It is the responsibility of the medical assistant to put the patient’s mind and body at ease. Provide an explanation of the process and purpose of the blood draw to help the patient feel comfortable with the procedure and confident in your abilities. Give a concise explanation of the procedure, while remaining friendly and professional. Let the patient know that blood will be drawn according to the provider’s request. Consult the patient about previous blood draws good or bad reactions to phlebotomy, sites where blood has been drawn before, and how the patient is feeling about the procedure.

After assembling all of the equipment and identifying and preparing the patient, place the patient in a comfortable, appropriate position for drawing blood.

SELECT APPROPRIATE SUPPLIES FOR TESTS ORDERED

Basic supplies and equipment are necessary for the collection of all venous blood specimens. Preparing the appropriate equipment prior to the phlebotomy procedure helps ensure the proper collection of blood specimens is completed.

Standard phlebotomy supplies

⦁Gloves: Ask patients about the possibility of latex allergies as part of the screening questions prior to assembling phlebotomy supplies.

⦁Tourniquet: Some facilities use latex tourniquets; screening questions about latex allergies with gloves will provide information regarding this issue.

⦁Isopropyl alcohol wipes: Standard for skin preparation for all draws except blood cultures.

⦁Nonalcohol prep kits or swabs: Used for blood cultures; can include povidone-iodine or

chlorhexidine gluconate swabs.

⦁Nonsterile gauze: Typically 2 x 2 size; avoid cotton balls.

⦁Cohesive wrap or paper tape: Applied postprocedure to aid in

hemostasis.

⦁Double-pointed needle: Typically 21- to 22-gauge; requires connection to plastic needle holder or sleeve.

⦁Butterfly needle: Also called a winged infusion; used for weak or fragile veins prone to collapse, such as in hand draws.

⦁Blood collection tube: Also called vacuum tube; sterile glass or plastic tube with a vacuum inside and a rubber, color-coded top to indicate chemical additive.

⦁Plastic or glass capillary tubes with clay sealant tray: Used for capillary blood testing; clay creates a seal at one end of the tube to avoid loss of the specimen.

⦁Sterile syringe, needle, and syringe transfer device: Used for syringe draws when a butterfly

needle is not available.

⦁Laboratory requisition and labels

⦁Ice or chemical cold packs: Used for postprocedure care as needed

Tube colors and additives

Vacuum tubes are identified by stopper color and additives. The tubes are color-coded for easy

identification of the chemical additive inside. The tubes must be drawn in the proper order to avoid cross-contamination of the additives. If the tubes are not drawn in the correct order, the additives could inadvertently affect the test. An inaccurate blood-to-additive ratio can also cause inaccurate test results, so fill phlebotomy tubes to the required quantities

SUPPLIES FOR NONROUTINE TESTS

In addition to routine venipuncture, medical assistants may perform various other types of blood collection and testing, such as blood cultures and micro-collection. Additional supplies for these types of blood collection can include micro-collection tubes for capillary blood requiring a chemical additive, capillary tubes, yellow top tubes, and vacuum culture vials for blood cultures.

Ekg and Cardiovascular testing

PERFORMING CARDIAC MONITORING (EKG) TESTS

The medical assistant must be familiar with the electrocardiograph

machine and be able to troubleshoot if not properly functioning. Efficient care of the equipment and proper preparation of the patient can reduce the need to troubleshoot

EKG equipment and supplies

EKG machines vary in size and shape, but all have basically the same parts. The multichannel EKG machine is a recorder that monitors all 12 leads at once; it can record three, four, or six leads at a time and print the recording on a single sheet of paper. The three-channel EKG unit is typically found in the ambulatory care setting and, as the name implies, records three leads at once. A single-channel EKG machine records one lead at a time and produces a running strip. As technology advances, more opportunities are available to record and transmit EKGs. Digital technology allows rapid collection and distribution of data across the health care system. This facilitates effective patient care, whereas the ineffective use of fax machines was once necessary to transmit results from one facility or provider to another. Computer-based monitoring, such as telemetry, is typically conducted in a hospital setting. In these situations, the patient is constantly monitored for any irregularities. Emergency equipment is readily available if interventions are needed. Other computer-based monitoring systems in the ambulatory care setting provide multiple capabilities including transmission, storage, and retrieval of EKG information. The electrodes are placed on 10 areas of the body to record heart activity from 12 angles and planes. Each electrode is impregnated with an electrolyte gel that serves as a conductor of the impulses, or a gel is applied and then an electrode and lead wire are attached. Both the electrodes and electrolyte gel are needed to transmit the impulses. Poor-quality or expired electrodes or gel can result in an artifact and interfere with the ability to produce a clean tracing. Electrocardiograph paper can be displayed in graph or dot matrix format, with vertical and horizontal lines or dots at 1 mm intervals. The vertical axis represents gain or amplitude. The horizontal axis displays the time. Each small vertical square represents 0.1 millivolts (mv). Each small horizontal square represents 0.04 seconds. Large squares are identified by darker lines and include five small boxes horizontally and vertically. The paper should be run at the normal speed of 25 mm/second. The normal amplitude is 10 mm or 1 mv. Be familiar with these figures to recognize obvious abnormalities that need to be reported to the provider immediately. The EKG graph paper is heat- and pressure-sensitive. Waveforms are burned onto the paper via a stylus that heats when the machine is turned on. Take precautions to avoid additional pressure contact via fingernails or other instruments when the EKG is being prepared for the provider

Performing the EKG

The medical assistant is responsible for connecting the electrodes and lead wires for the EKG.

Preparing the patient will likely take longer than the actual test. If possible, patients should have been instructed to avoid applying any substance to the skin (such as lotions, powders, oils, or ointments) prior to the testing. Help ensure that the skin is clean by using alcohol wipes or soap and water at the attachment sites. Some facilities have electrolyte pads to prep the site. Excessive chest hair presents challenges with electrode adherence to the skin. If the medical assistant cannot properly place the electrodes with normal skin prep, the next step is to clip the hair. If necessary, small areas might need to be shaved. Once the patient has been prepped for the procedure, attach the electrodes and leads. The limb electrodes should be placed on fleshy areas of the skin and within the same general vicinity on each limb. For instance, if the left lower leg has been amputated, it can be necessary to place the electrode on the left lower abdomen. Thus, the right lower leg electrode would be placed on the right lower abdomen. The first six recorded leads originate from the arms and legs. Leads I, II, and III are bipolar and record impulses that travel from a negative to a positive pole at specific positions in the heart. Lead I records impulses between the left and right arms. Lead II records impulses between the right arm and left leg. Lead III records impulses between the left arm and left leg. Leads AVL, AVR, and AVF are unipolar, but due to poor illustration of the waveforms must be augmented and therefore get assistance from two poles to enhance the tracing. In AVL, the left leg and right arm assist with the left arm tracing. In AVR, the left arm and left leg assist with the right arm tracing. In AVF, the right and left arms assist with the left leg tracing. Once the electrodes are in place, the medical assistant connects the precordial lead wires following the contour of the body and takes care to avoid excessive tension or crossing of the wires, which could lead to artifacts within the tracing.

The medical assistant should be familiar with the universal lead wire colors in case markings arenot clearly visible.

⦁ White:right arm

⦁Black:left arm

⦁Red: left leg

⦁Green: right leg

Precordial leads can be all brown or individually colored.

⦁V1: red

⦁**V2:**yellow

• V3**:**green

⦁**V4 :**blue

⦁**V5:**orange

⦁**V6:**purple Using anatomical landmarks, place the six chest leads in a systematic

order, taking care to avoid placing electrodes over the bone (See Figure13.3). All precordial leads are unipolar and record electrical activity from different parts of the heart.

⦁V1: the right side of the sternum at the fourth intercostal space

⦁ **V2:**left side of the sternum, directly across from V1 at the fourth intercostal space

⦁**V4:**the left side of the chest, fifth intercostal space, midclavicular line

⦁V3: the left side of the chest, midway between V2 and V4 (NOTE: V4 is placed before V3 because of this)

⦁**V5:**the left side of the chest, fifth intercostal space, anterior axillary line

⦁**V6:**the left side of the chest, fifth intercostal space, midaxillary line

Most EKG machines in the ambulatory care setting today perform standardized functions and run automatically once the start button is pushed. It can be necessary to enter specific patient data that includes items such as name, date of birth, sex, medications, and date and time of the procedure. This information will appear on the patient tracing in the electronic record.

Waveforms, intervals, and segments

Each waveform, interval, and segment has significant meaning on the EKG. The medical

assistant is not expected to diagnose conditions but must have an awareness of obvious

normal vs. abnormal tracings.

P wave: Represents atrial depolarization or contraction.

QRS wave: Represents ventricular depolarization or contraction (atrial repolarization is not visible but occurs during this phase).

T wave: Represents ventricular repolarization or relaxation.

U wave: Not always visible but represents a repolarization of the

bundle of His and Purkinje fibers.

P-R interval: Starts at the beginning of the P wave and ends at the beginning of the Q wave.

It represents the time it takes from the beginning of atrial depolarization to the beginning of

ventricular depolarization

QT interval: Starts at the beginning of the Q wave and ends at the end of the T wave. It represents the time it takes from the beginning of ventricular depolarization to the end of

ventricular repolarization.

ST segment: Starts at the end of the S wave and ends at the beginning of the wave. It represents the time from the end of ventricular depolarization to the beginning of ventricular repolarization.

The medical assistant should monitor the tracing as it is being recorded to ensure that leads were connected properly and that artifacts are not appearing. Items that should be visible include a universal standardization mark, a baseline that is tracking through the middle of the tracing, no abnormal spikes in the baseline, and visible P, QRS, and T waves. Unless there is cardiac pathology, waveforms should also be positively

deflected. The procedure should be relatively quick and noninvasive, but constant monitoring is required. Take any complaints of chest pain seriously and notify the provider.

Patients who are in a recumbent position can experience syncope upon rising. This can be

minimized by having the patient sit for a short while before standing.

Patients can experience dyspnea when lying flat if they have COPD or other lung disorders. Avoid or minimize this by elevating the head of the bed to a semi-Fowler’s position and efficiently completing the EKG. Once electrocardiography is completed, detach all leads from the electrodes, and remove and discard electrolyte pads. Inspect the skin for irritation at the connection sites. Thank the patient for cooperating and providing privacy for redressing

Patient care coordination and education

COORDINATING CARE WITH COMMUNITY AGENCIES

There are many services within the community that can benefit patients. Be aware of what services are offered and offer contact information for those services. Brochures from organizations are usually free and available to hand out. Keep a list of community resources in an easily accessed location so that information can be provided to patients without any delays. Depending on the specialty of the practice, lists can be organized according to patients’ condition, age, or socioeconomic status. The Centers for Disease Control and Prevention website has resources that provide services within specified geographic locations. Local hospital websites also provide information regarding outreach programs offered in the community. Document all information provided to the patient documented in the health record; this aids in promoting the continuity of care

TEAM-BASED PATIENT CARE

Team-based health care creates a partnership between providers and patients to ensure patients are educated and actively involved in their care. Every team member is accountable for providing quality care. This approach requires communication among all members of the team. Two common healthcare delivery models that practice team-based patient care include the patient-centered medical home(PCMH) and accountable care organization (ACO). In both models, the patient is the focus with all members of the team working to provide the best outcome for the patient using a holistic healthcare approach.

Roles and responsibilities

The implementation of payment models such as “pay for performance” requires a specific mindset for those delivering health care. The patient’s health is everyone’s responsibility. In organizations that practice team-based care, team members work collaboratively to provide seamless care. This allows patients to obtain the best care possible without interruptions. Everyone works at the top of their license or credential in these settings by aligning staff responsibilities to their credentials. For team-based care to be effective, many clinicians are needed to address all needs of the patient. Primary care providers include the physician, nurse practitioner, or physician assistant. Other healthcare providers include mental health specialists; physical, occupational, and speech therapists; pharmacists; nutritionists; and dentists. Patients who have chronic conditions are usually assigned a nurse case manager to follow them throughout their disease. Support staff (medical assistants, administrative staff members) also play a key role in team-based care settings.

Specific roles of team members

The primary care provider (PCP) is the first provider the patient seeks care from. One of the PCP’s main goals is to coordinate preventative health care services (regular check-ups, screening, tests, immunizations, health coaching). PCPs can be family practitioners, internal medicine or doctors of osteopathy (DO), or pediatricians. Pediatricians offer preventative care services and treat common pediatric conditions such as viral infections or minor injuries.

A specialist is a provider that diagnoses and treats conditions that require a specific area of

expertise and knowledge. Primary care providers may refer patients to a specialist to diagnose or treat a specific short-term condition. For chronic diseases, patients can work with specialists for an ongoing period of time.

Physician assistants (PAs) have similar training to physicians and are licensed to practice

medicine as long as they are supervised by a medical doctor (MD). PAs can conduct physical exams, provide preventative care, prescribe diagnostic tests, assist with surgical procedures, diagnose illnesses, and prescribe medicine.

Advanced practice nurses have more education and experience than RNs and can usually perform the same tasks as physician assistants. Clinical nurse specialists, nurse anesthetists, nurse practitioners (NP), and nurse midwives are common advanced practice nurses.

With a nationwide shortage of physicians going into primary care, PAs and NPs is a solution that is more cost-efficient than physicians.

Registered nurses (RNs) are licensed by individual states and have an associate's or bachelor’s

degree in nursing. RNs usually oversee the case management of patients who have complex chronic conditions. They also coach patients about their overall health.

Practical nurses (PNs) are sometimes referred to as vocational nurses and are also licensed by individual states. PNs usually train for approximately 1 year at a community college or vocational school, receiving a diploma or associate degree. These healthcare professionals often triage phone calls, administer medications, and assist with other clinical duties in the clinical setting.

Pharmacists prepare and dispense medications prescribed by authorized providers. They must be knowledgeable of individual and various combinations of medicines to be able to educate patients on their use and answer questions about side effects. Using a pharmacist to implement medication therapy management is relatively new to ambulatory care

Dentists diagnose and treat issues relating to the teeth and mouth. Dentists also educate patients on ways to prevent problems with oral health. Many community health centers include oral health services to patients.

Occupational therapists assist and educate patients on how to perform everyday tasks after a

physical, mental, or developmental disability has occurred. Physical therapists

assess a patient’s pain, strength, and mobility and then develop a treatment

plan to improve any areas of concern.

Speech therapists or speech-language pathologists work with patients who have problems with speech and swallowing due to an injury, cancer, or stroke. They focus on helping a person work toward improving, regaining, and maintaining the ability to communicate, chew, and swallow. Some clinics offer rehabilitation services. Having therapy services within the clinic is an added convenience for many patients and improves the communication process between providers and therapists. Psychiatrists are MDs who diagnose, prescribe medications and treat mental, behavioral, and emotional disorders.

Psychologists are not MDs but have a doctor of psychology (PsyD) or a doctor of philosophy degree (Ph.D.). They work with patients who are experiencing mental health challenges, especially during times of stress or emotional turmoil.

Social workers assist patients and families in times of transition or crisis. They assist patients in a clinical or hospital setting with physical, emotional, and financial issues related to an illness or injury. Social workers often coordinate additional services (transportation, housing, access to meals, financial resources, long-term, hospice services).

Providers on the mental health team that work in the PCMH or ACO usually contract with the

facility to work a specific number of hours per week. Clinics with a large census can include a full-time social worker as part of their permanent staff

registered dietitian nutritionist (RDN) is an expert in diet and nutrition. RDNs educate patients

on the connection between chronic disease and poor nutrition, assist with menu planning, and help low-income patients obtain healthier foods at lower prices.

Some patients rely on religion or spirituality to cope with an illness or injury. Priests, ministers, and rabbis are some clergy members who often provide patients with this spiritual support.

Support Staff

Administrative and clinical staff professionals are also key players in providing the best possible

experience for health care consumers. Scheduling appointments, answering phones, greeting

patients, maintaining medical records, assisting providers during exams/procedures, performing measurements, processing billing, completing insurance forms, performing laboratory or other diagnostic services, and managing financial records are some of the responsibilities of the administrative and clinical support staff in a medical office. Here are a few examples of these jobs.

⦁Clinic Coordinator

⦁Medical administrative assistant

⦁Clinical medical assistant

⦁Medical records specialist

⦁Medical billing specialist

⦁Financial counselor

⦁Scheduler

Patients and family members

The role of the patient and family members is more active in patient-family-centered health care than in the traditional delivery of health care. The wants and needs of the patient and family are the focus areas in this type of delivery. All parties have a say in how the patient receives treatment, what those treatments will be, the desired outcome, and education and counseling to achieve these goals. The key to achieving full participation of patients and their families is good communication. When this is successful, patients report improved symptoms and overall better outcomes. When patients feel like they are in partnership with their provider, they have increased satisfaction with their care. Fewer hospitalizations, less testing, and fewer treatments are also achieved with successful patient-family-centered health care. As a result, healthcare costs are also decreased

Institute for Health Care Improvement Triple Aim

The Institute for Health Care Improvement (IHI) has a rubric for health care transformation. The

three goals are:

⦁Improving the experience of care.

⦁Improving the health of populations.

⦁ Reducing costs of health care.

Methods for meeting these goals are the implementation of either a PCMH or ACO. These models both use the team-based or patient-family centered care model. For the IHI Triple Aim to be met, all three goals must be accomplished

Health care models that practice team-based care

The enactment of the Affordable Care Act emphasizes the need for team-based medicine. The three main goals of ACA were to:

⦁Expand health insurance coverage.

⦁Shift the focus of health care delivery system from treatment to prevention.

⦁Reduce costs and improve the efficiency of health care

FACILITATE PATIENT COMPLIANCE TO OPTIMIZE HEALTH OUTCOMES

Checking in with the patient or patient’s family

The best method to promote compliance is through communication. This can be achieved through telephone calls or e-mailing through a secured server, depending on the patient’s preference. This is part of maintaining HIPAA compliance. Also check to see if any family members are authorized to receive the patient’s health information. It is the patient’s right to restrict who receives any information. Follow-up communication is critical to promoting compliance and for clarity of goals. Any questions the patient has are easily answered, and any worries or fears regarding medication side effects can be alleviated. The patient feels cared for, and the provider is aware that the treatment plan is being followed

Administrative assisting

SCHEDULING AND MONITORING PATIENT APPOINTMENTS

Several methods can be used when scheduling patient appointments. While the most common practice is use of electronic software, some offices still use an appointment book. Either method is acceptable, but the use of practice management software to develop a

matrix or an electronic template can make appointment scheduling easier. Consider the type of appointment scheduling to be used, as well as the protocols for scheduling specific types of appointments. Written policies regarding routine, acute illness, no-show , and rescheduled appointments are needed for consistency.

Electronic vs. paper-based systems

Medical records consist of an electronic medical record system or a paper-based medical record system. The preferred method for tracking and documenting patient data has become the electronic health record. Paper charts are tangible records comprised of documented proof of patient care. However, paper charts have some significant disadvantages. They can only be used by one person at a time, can easily be misplaced due to filing errors, and cannot be easily shared with other providers. The electronic medical record can accomplish a significant number of tasks using one system. Many tasks can be performed within the electronic medical record. Electronic medical records help decrease medical errors, as well as time spent correcting diagnoses and procedure coding for medical billing. This decreases the time needed for insurance reimbursements. In addition, the electronic medical record provides a secure way to communicate with the patient regarding medication refills, upcoming appointments, and the status of referrals

Scheduling software

Medical assistants use practice management software to search for appointments with criteria such as specific providers, available times, types of appointments, and additional search functions based on a set matrix

Establishing a matrix

The use of a template allows the medical assistant to establish a matrix for setting appointments and blocking off specific time periods for holiday, meetings, and lunch breaks. The template for each matrix can be used repeatedly for each provider over any length of time. Appointments may be grouped by provider, appointment types (new patients, OB patients, allergy patients) and available resources (surgery room, laboratory). Additionally, the matrix can be adjusted based on future needs as they arise.

Types of scheduling

Several types of scheduling methods can be used based on the facility’s, provider’s, and patient’s needs. Wave scheduling, modified wave scheduling, and double-booking are some common types of scheduling. Wave scheduling allows three patients to be scheduled at the same time, to be seen in the order in which they arrive. In this method, one patient arriving late does not disrupt the provider’s schedule. Modified wave scheduling allocates two patients to arrive at a specified time and the third to arrive approximately 30 minutes later. This timely sequence is continuous throughout the day. Double-booking is when two patients are scheduled at the same time to see the same provider. This is often used to work in a patient with an acute illness when no other time is available. It creates delays in the provider’s

schedule that continue throughout the rest of the day.

Internal appointments or established patients

The first piece of necessary information for scheduling an internal appointment with an

established patient is the patient’s name and date of birth. Next, determine the reason for the visit, as well as the amount of time the patient and provider will need for the visit. Lastly, determine if there is any day of the week or time the patient prefers. All elements should be considered, including availability, provider preferences, and patient habits.

External appointments or new patients

Information needed for scheduling an external appointment for a new patient begins with obtaining demographic information. This includes full name, address, date of birth, and contact phone information needed for scheduling an external appointment for a new patient begins with obtaining demographic information. This includes full name, address, date of birth, contact phone numbers, insurance information for billing purposes, Social Security number, and emergency contact information. Have new patients complete a registration packet prior to the visit, if possible. These packets usually comprise new patient forms for documenting demographic information, Notice of Privacy Practices, and patient medical history form, which includes current medication numbers, insurance information for billing purposes, Social Security number, and emergency contact information. Have new patients complete a registration packet prior to the visit, if possible. These packets usually comprise new patient forms for documenting demographic information, Notice of Privacy Practices, and patient medical history form, which includes current medications

Duration of appointment

Always adhere to the office policies and protocols when scheduling patient appointments. When determining the duration of a patient appointment, consider the provider’s preferences, the patient’s needs, whether the patient is established or new, and room availability. With effective scheduling, the patient should not wait more than 15 minutes in the waiting area for the appointment.

Urgency of appointment

All calls that come into the office should be evaluated and prioritized based on a

screening process. Obtain the caller’s full name, phone number, and address at the beginning of a call when the patient’s symptoms point toward a life-threatening condition. A list of questions should be prepared by the provider or practice manager for the medical assistant to reference when determining whether the call is routine, urgent, or life-threatening. If the situation is deemed critical and emergency services are needed, keep the caller on the phone until emergency medical services arrive to ensure the safety of the caller

Handling cancellations and no-shows

The medical practice should have a policy for individuals who fail to keep appointments or routinely cancel appointments. Patients cancel and miss appointments for a variety of reasons that can be beyond their control. Each incident should be recorded as part of the medical record to keep a detailed legal record of how many times a patient has canceled or missed scheduled appointments. Some practices have policies that allow for charging a fee for the missed visit. Providers may discharge the patient from the practice if continued cancellations or missed appointments take place, as this demonstrates non-compliance. It is imperative that all appointments missed are documented to protect the provider from legal action. The medical assistant should be familiar with the established office policies for these situations.

Recalls (electronic and manual)

An automated call routing system offers patients the option of canceling, confirming or rescheduling an appointment. This automated system keeps track of which patients have confirmed, which patients will not be coming for their regular scheduled appointment, and which patients request a call back to reschedule. It is also good practice to contact patients who have opted to cancel to ensure continuity of care and good customer service.

VERIFYING DIAGNOSTIC AND PROCEDURAL CODES

Diagnostic and procedural coding translates written descriptions of diseases, ailments, injuries, or any health encounter into numeric or alphanumeric codes. The correct use of diagnostic and procedural coding is ensured by accurate and efficient medical record maintenance and claims processing. Each code identifies a specific encounter, ailment, or injury. Each diagnostic and procedural code allows for the submission of services for reimbursement from insurance companies and provides statistical data for research studies

Medical coding systems

For an illness to be properly coded, a recognized and established structure for coding must be used

ICD-10-CM

ICD-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. There are three to seven characters used. The first character is alphabetical. The second and third characters are numeric, with the fourth, fifth, sixth, and seventh being either alphabetic or numeric. A potential placeholder provides for future expansion of the codes. This allows for more specificity and laterality

ICD -10 -PCS

ICD-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. These codes are a replacement for ICD-9-CM, Volume 3.

CPT codes and modifiers

Current Procedural Terminology (CPT) codes and modifiers are used to document procedures and technical services based on services by providers in outpatient settings. All information in the medical record must be accurate for the correct code to be documented. In addition, using the appropriate codes assists in communicating data on procedures and services, correct filing of insurance claims, and provides basic information for statistical analysis of health care services.

HCPCS

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, HCPCS codes are updated every year. They are designed to enhance uniform reporting and collection of statistical data on medical supplies, products, services, and procedures. These codes are typically used for Medicare and Medicaid insurance plans.

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. This helps reduce the amount of claim denial

Billing inquiries

All billing inquiries should be handled in a prompt and courteous manner. If the patient is calling about an error, place the patient on hold while the account is being pulled up for review, thank the patient for holding, explain the charges carefully, and make sure all questions and concerns have been answered. If the medical assistant is unable to resolve the issue, obtain the patient’s contact information so the appropriate staff can contact them once the issue has been investigated and the solution has been determined.

Steps to appeal a denial

When filing an appeal for a denial received from an insurer, first determine why the claim was

denied. Then obtain and complete the insurance company’s appeal document. The appeal document must be filed as quickly as possible so that it doesn’t exceed the time needed for filing. Include a letter from the provider to provide support for medical necessity, progress notes from the treating provider, and relevant results from any testing performed

INVENTORY OF CLINICAL AND ADMINISTRATIVE SUPPLIES

Medical assistants can be responsible for maintaining inventory and ordering supplies for the

office. This is to ensure administrative and clinical staff have all the supplies they need to properly function on a daily basis. Supplies should be ordered, checked against the shipping or packing list when they arrive, and stocked in a secure location in the office that is easy to access by personnel. Communication in the office is essential when stock is running low. Without the appropriate supplies stocked, the provider and medical assistants might not be able to complete all their duties or perform needed tests and procedures. This can create an inconvenience for patients if they need to return to the office at a later date

Administrative and clinical supplies

A few administrative supplies are essential to everyday work functions.

⦁Pens

⦁Pencils

⦁Reams of paper

⦁Toner cartridges

⦁Paper clips

⦁Registration forms

⦁Patient information sheets

⦁Clipboards

The supplies needed are dependent on the office specialty and amount of in-office procedures

performed. If the office is computerized, the needed supplies may be decreased. Inventory of

supplies is very important to maintain the workflow of the office

BILLING PATIENTS, INSURERS AND THIRD-PARTY PAYERS

Medical offices process insurance claims for patients as a courtesy because most patients do not understand the process that is involved. Medical assistants are responsible for working to obtain maximum benefits and reimbursement from the patient’s insurance and third-party payers for services rendered. Make sure all procedures and services that were performed by the provider are listed correctly and appropriately on the claim so that the correct reimbursement will be received

Financial terminology

Medical assistants should be familiar with the following financial terminology, definitions, and how to use these terms. Account balance is the total balance on an account; it can be a

debit (negative) or credit (positive). Accounts receivable is the amount owed to the provider for the services rendered. Accounts payable is debt incurred but not yet paid; this can be for supplies or utilities. Debits represent a record on an account as an addition to expenditure or asset accounts or a subtracted amount from income. Credits are an entry on an account represented as an addition to profits. Assets are the property of an individual or organization that is subject to payments for debts owed. Liabilities are items that are outstanding (debts)

Billing methods

Two types of billing methods are manual and computerized systems. A computerized billing system uses software to generate a report for accounts according to the last time a payment was made. Medical assistants can use this report to determine which accounts are 30, 60, or 90 days old. The manual billing system is also used this way, but with a different process. Accounting forms, ledgers, or receipts are often used on a peg board system. Manual billing still provides the medical assistant with all record entries, collections, and receivables. However, it is cumbersome and time-consuming and requires significantly more time to process than computerized billing systems. Once a report is generated, the medical assistant will use the data to determine which patient accounts need to be sent their monthly billing statement and which need to be sent to collections. Once a month's billing is generated, it is usually sent before the 25th of each month to reach the patient by the last day of the month. This form of billing encourages the patient to send payment at the beginning of the month. Some offices prefer cycle billing, which divides accounts into small alphabetic or color-coded groups, regardless of changes on the account. This method ensures statements will be sent by specific dates so the payments on the accounts remain distributed throughout the month. When billing is spread out over the course of the month, more time and care are given to each statement. This reduces the likelihood of accounting errors

Payment methods

Most medical offices accept credit cards, debit cards, checks, and cash. Credit and debit cards are widely accepted for convenience, but there is a small fee charged for each transaction. In the case of a hardship or a large bill, credit arrangements may be made. The medical assistant must provide a detailed explanation of fees, services, and charges, as well as convey a tactful and courteous explanation of the payment plan. Discussion of the payment processes and all other information must be documented and signed by an authorized member of the office and the patient. This documentation must be attached to the patient’s financial record with a copy given to the patient. If a check is returned to the medical office for nonsufficient funds (NSF), the medical office has the right to charge additional fees to the patient’s account. This information needs to be displayed prominently throughout the office and be shared with each patient prior to their first encounter.

Posting charges and payments

Charges and payments to patients’ accounts are either entered into the computer system or

manually entered onto a ledger and a day sheet using the pegboard method. As soon as the patient submits the payment, the medical assistant can mark the charges as paid. It is important to include the check number or type of credit card used, and where the payment originated (patient, insurance). This allows for easy tracking in case of any discrepancies

Making adjustments

When the provider participates with insurance, medical assistants have to make adjustments

to patient accounts for insurance disallowances. Other circumstances may be for professional

discounts, account write-offs, or payments sent to the practice after the account has been placed in collection status. If the patient or guarantor files for bankruptcy, all charges must be adjusted off the account.

Online banking for deposits and electronic transfers

Online banking allows for electronic fund transfers (EFTs) for payroll disbursements, money

owed to business institutions, and payments from insurance companies and other governmental organizations. When insurance payments are made through EFTs, the amount is deposited 1 to 2 weeks faster than a conventional check. EFTs are processed through an automated clearinghouse that follows federal rules and regulations. Medical assistants are responsible for promptly making daily deposits to ensure accuracy in the daily reconciliation of the cash drawer, day sheets, and patient accounts. When checks are received, it is important that deposits are made daily. This allows for funds to pay accounts payable and reduce any issues with stop payments or stolen checks, and it is also a courtesy to the payer

ENTERING INFORMATION INTO DATABASES OR SPREADSHEETS

Medical assistants often use spreadsheets for reports or enter information into the electronic medical record database. After new information has been entered, periodically save the spreadsheet. In addition to tracking patient data, spreadsheets can be used for inventory lists and personnel functions

Computer literacy

The medical assistant should be familiar with basic computer terms. For example, a network is a group of two or more computer systems that are connected together. Be careful when accessing outside sources from a workplace computer. Any website visited needs to comply with the organization’s network security protocols and policies. The use of unauthorized websites and suspicious downloads can increase the chances of violations of patients’ protected health care information (PHI). All patients are entitled to the utmost confidentiality regarding the personal nature of their medical records

Word processing and typing

It is necessary to be familiar with programs such as Microsoft Word, Excel, PowerPoint, and

Outlook, which is used in many medical offices. Medical assistants use word processing software, such as Microsoft Word, to create and modify documents. Features like Mail Merge are useful for developing a set of emails, letters, faxes, or printing labels and envelopes for correspondence and mass mailing

Data entry and data fields

A data field is a location where data is stored within a computer program. The term generally

denotes an area in a database or a section in a form that needs to be completed, on paper or

electronically. Data entry is the act of typing or writing information into the field

Common databases used in healthcare

The most commonly used database in health care is the electronic medical record (EMR) and the electronic health record (EHR). Electronic health records can be created, managed, and consulted by authorized clinicians and staff from more than one healthcare organization. Electronic medical records can be created, gather, managed, and consulted by authorized clinicians and staff within a single healthcare organization. In both the EHR and EMR, information is arranged into different areas within the system. Examples are demographics, insurance, clinical information, and accounts. Each database holds information that can be grouped by using certain criteria. This allows for reporting on specific conditions or demographic information across a large population

PREAUTHORIZATIONS AND CERTIFICATIONS

Using the information on the reverse side of the patient’s insurance card or on the insurance website,

medical assistants can determine what type of services need preauthorizations or recertification. Preauthorization is a process required by some insurance carriers in which the provider obtains permission to perform specific procedures or services or refers a patient to a specialist. Most managed care and HMO insurances require preauthorization prior to patients receiving any procedures or treatments outside of the primary care office. Patients need to be made aware of covered and noncovered benefits, as well as financial information (required copayments, deductibles) when seeing specialists, as the financial obligations are typically higher. These services are typically for nonemergent surgeries, expensive medical tests, and medication therapies. The medical assistant needs to include the following when obtaining or verifying prior authorization.

⦁Authorization code

⦁Date the authorization is effective

⦁Date the authorization expires

⦁Authorized diagnosis and procedural codes

⦁Contact information for the specialist office

⦁How many visits are authorized

⦁What authorization has been issued for

Procedures that need to be precertified

If a patient is hospitalized, most insurance companies usually require precertification within 24

hours of admission. Precertification is a process required by some insurance carriers in which the provider must prove medical necessity before performing a procedure. Precertifications are also sometimes required for specific types of laboratory tests, diagnostic testing, and procedures that are considered unusual or expensive (MRI, chemotherapy medications)

Participating providers

Patients can contact a provider’s office to inquire if the office or provider is participating with their insurance plan. If a provider is nonparticipating and the patient is seen, the claim will be denied or reimbursement will be reduced because the provider is not in-network with that insurance company. Participating providers with any insurance company agree to adjust the difference between the amount charged and the approved contracted amount the insurance company will reimburse. If the provider’s office is participating, they agree to bill the patient for only the deductible, copay, coinsurance, or amounts due based on allowed fees set forth in the contract between the provider and insurance company. In return, the insurance company agrees to pay the provider’s office directly for covered services rendered to the insured

CHARGE RECONCILIATION

The medical assistant is responsible for completing charge reconciliation. The first step in this

process is to add deposits, deduct outstanding checks, and deduct bank service charges, NSF

checks and fees, and check-printing charges. Next, add the interest earned along with any notes receivables (EFTs) collected by the bank. If the bank statement and office accounts do not balance, initiate a full investigation. When the error is discovered, add or deduct errors in the company’s cash account. Compare the adjusted balances and record all adjustments to reconcile the balance. This is an audit to confirm accounts are accurate and that the bank is managing funds correctly.

Obtaining accounts receivable total

Balance and obtain an accounts receivable total once a month after posting all charges and

payments have been completed. To obtain the total, pull a list of all accounts with a balance and then add all balances for a total figure. This figure should equal the accounts receivable balance from the daily control cumulative total. If a pegboard system is used, the total for daily, weekly, monthly, and yearly amounts will be listed on the side of the day sheet. All ledgers should be tallied and compared to the totals on the day sheet on a monthly basis

Aging reports, collections due, adjustments, and write-offs

Before a medical practice submits any accounts to collections, all avenues for collection should be exhausted. To determine if an account is delinquent, run an aging report. Aging reports are grouped by the day of the last payment or by the date of service if no payments have been made. The date categories are 0 to 30 days, 30 to 60 days, 60 to 90 days, and 90 to 120 days. Depending on office policies, the medical assistant makes a friendly reminder call, letters are mailed encouraging the patient to make a payment or set up a payment plan, and if all else fails, a certified letter is mailed requesting payment before the account is sent to collections. When the final notice is sent, the account must be sent to collections and all further patient contact regarding the account must be discontinued. Always treat the patient with respect and follow office policies and procedures when making payment arrangements

Communication and customer service

PREPARE WRITTEN AND ELECTRONIC COMMUNICATIONS

Written communication involves any interaction that uses the written word. Written communication used internally for healthcare organizations includes memos, reports, bulletins, job descriptions, employee manuals, and emails. One advantage of electronic business correspondence is that messages do not have to be delivered on the spur of the moment; instead, they can be edited and revised several times before they are sent to ensure the message is clearly communicated. It also provides a permanent record of messages that have been sent and can be saved for future reference. There are potential pitfalls associated with written communications. Unlike oral communication in which impressions and reactions are exchanged instantaneously, the sender of written communication does not generally receive immediate feedback. Written messages often take more time to compose due to their information-packed nature and the difficulty that many people have in composing such correspondence.

Internal communications

Sharing information within an organization for business purposes is considered

internal communication. Internal communication includes face-to-face conversations, telephone calls, interoffice mail, paging, faxing, closed-circuit television, and email

External communication

External communication is the transmission of information between a business and another person or an entity outside of the company’s environment. It is important for all formats, grammar, and spelling to be accurate. External communication includes face-to-face communication, print media (newspapers, magazines, flyers, newsletters), broadcast media (radio, television), and electronic communication (websites, social media, email). All external communication is a representation of the medical practice and must be professional and appropriate.

Business letter formats

Business letters are written with the intention of getting the reader to respond. They should be

written with a clear purpose, error-free, friendly, and pertinent. All business correspondence should

be on company letterhead and written in a standard format. Business letters have the following

elements.

⦁ Heading: The letterhead and dateline (month fully spelled out, day, and year)

⦁Opening: The recipient’s address and salutation

⦁ Body: The content and information to be communicated

⦁ Closing: The complimentary closing and signature

Preparing faxes

Fax machines are still used in the health care industry. Fax machines allow documents to be

securely transmitted with end-to-end encryption. Always use a cover sheet that discloses that

confidential information is attached

Email communication

Email is inexpensive, efficient, and can be used internally and externally to convey information. It can be easily archived for reference or printed if hard copies are needed. With all of the advantages, remember that emails provide a permanent, traceable record of communication. Be sure to use proper punctuation and grammar, appropriate subject lines, and clear and concise verbiage

Communicating with patients through the patient portal

Medical assistants can communicate with patients through a patient portal. Patient portals typically offer around-the-clock access to personal health information. Some portals allow patients to request prescription refills, make scheduling requests, communicate with

providers, and make payments. Patients can view recent testing and lab reports once the provider has signed off on them. Strict security measures require each patient to have a unique login. One of the main reasons for offering a patient portal is to increase

communication between the healthcare team and the patient. Satisfaction and overall quality of care increase when patients are more engaged in their health care; the use of a patient portal can facilitate this engagement

MODIFY COMMUNICATION-BASED ON SPECIAL CONSIDERATIONS

Patients who have impaired vision, hearing, or speech use a variety of ways to communicate.

Patients who are blind can give and receive information audibly, and patients who are deaf can give and receive information through writing or sign language. A telecommunication

relay service, video relay service, or a translator can be used to communicate with patients who need accommodations

Patient characteristics affecting communication

Barriers to communication include differences in language, culture, cognitive level, developmental stage, sensory issues, and physical disabilities. When patients and health professionals have different language proficiency, there is a barrier to effective communication. Unfortunately, this language barrier is often not immediately evident. Patients and providers can underestimate the language barrier. Cultural differences are also a barrier; culture affects the understanding of a word or sentence and even the perception of the world. Low health literacy is a barrier due to the inability to understand the provider’s medical jargon or complex instructions. Patients have the right to be fully informed about their care. Effective communication is a prerequisite to safe healthcare