CONDITIONS, INSTRUMENTS, AND PROCEDURES:

ROOTS, PREFIXES, SUFFIXES, AND PLURALS

Roots, prefixes, suffixes, and plurals

As familiarity with medical terminology grows, it becomes easy to notice similarities among these terms. That is because many of them share common roots, prefixes, and suffixes. These components can be used to create medical terms for conditions, instruments, and procedures. It’s not foolproof; it doesn’t work to just mix and match three components and find a word that is in universal use. For example, “hemi” means half, “narc” means sleep, and “ism” means condition. But if a patient chronically gets half the amount of sleep he should get, he doesn’t have heminarcism. There is no such word. Also, with some combinations, the result requires interpretation, because the literal meaning might vary a little from the actual meaning. An example is antibiotic, a combination of the prefix “anti,” meaning against, and the word root “bio,” meaning life. Antibiotics are not incompatible with life. They kill a particular type of living organism, bacteria. Another thing to remember is that not all medical terms adhere to the prefix-root-suffix schema. However, looking at words that have any one of those word components in it can offer a clue to what the term means. Understanding how these components interact can help clarify the terms used for thousands of medical conditions, instruments, and procedures

Common word roots by body system

Word roots are the core component of many words. Medical terms usually have one root but can have two or more. Sometimes, when a root attaches to a prefix or suffix, it needs an extra vowel to combine the components. For example, “hem” means blood and “rrhage” means excessive flow. The “o” between the two creates the medical term hemorrhage, meaning excessive blood flow. Not all word roots relate to a body system or a body part, but the following table lists some of the terms that do

Other common word roots

Here is a list of some of the word roots that apply in general clinical

practice and/or across multiple body systems.

Combining forms

A combining form is a word root with a combining vowel. Often, the combining vowel makes the medical term easier to pronounce. In most cases, the combining vowel is an “o,” but it is sometimes “i” or “e.” A combining form should be used when the last word root in a medical term connects with a suffix that begins with a consonant. When the word root connects with a suffix that starts with a vowel, just the word root should be used. Refer to the examples below

Notice that when the suffix begins with a vowel, the word root is used. Examples include

“cephalalgia” and “colectomy.” However, when the suffix begins with a consonant, the combining form is used, as in “colostomy” and “cephalodynia.” When connecting two-word roots, always use the connecting vowel, even if the following word root begins with a vowel

Common prefixes

Prefixes are word components that appear at the beginning of a word to change the meaning of the rest of the word. They generally mean the same thing in each word they modify. Some

medical terms have no prefix. An example is splenectomy, a combination of the word root

“splen,” meaning spleen, and the suffix “ectomy,” meaning removal. Here is a list of some of the

common prefixes medical assistants will encounter.

Common suffixes

Suffixes are word components that appear at the end of the word to change the meaning of the rest of the word. Some medical terms have no suffix, such as appendix. Some medical terms combine a prefix and a suffix with no word root. An example is hemiplegia, a combination of the prefix “hemi,” meaning half, and the suffix “plegia,” meaning paralysis . Here is a list of some of the common general suffixes medical assistants will encounter, as well as some that are more specific to clinical disorders and medical, surgical, and diagnostic procedures

DIETARY NEEDS AND PATIENT EDUCATION

The amount of nutritional information available can feel overwhelming. What is important is to

understand and become familiar with the information patients will need to hear often to assist

them in maintaining optimal health and managing various diseases and disorders. Medical nutrition is a huge field, and patients should not expect medical assistants to be experts in all this field entails. Referrals to dietitians and nutritionists are an appropriate way to help patients who need nutritional overhauls to improve their health. The keys to optimal nutrition are balance, variety, and moderation.

Major food groups

Fruits

Fruits include berries, melons, stone fruits, and fruit juices. MyPlate

lists the following benefits of eating fruits and vegetables every day.

⦁Reduces the risk for heart disease, including heart attack and stroke.

⦁Protects against some types of cancer.

⦁Reduces the risks of heart disease, obesity, and type 2 diabetes

mellitus.

⦁Lowers blood pressure, helps reduce bone loss, and reduces the risk

of developing kidney stones.

⦁Lowers calorie intake.

Any fresh, canned, frozen, or dried fruit or 100% fruit juice counts as

part of MyPlate’s fruit group. In general, 1 cup of fruit or 100% fruit

juice, or ½ cup of dried fruit makes up 1 cup from the fruit gr

Vegetables

The benefits of eating vegetables are similar to those for fruits. Any raw, cooked, fresh, frozen,

canned, or dried/dehydrated vegetable or 100% vegetable juice is in the vegetable group. In general, 1 cup of raw or cooked vegetables or vegetable juice, or 2 cups of raw, leafy greens equals 1 cup from the vegetable group

Grains

Grains include bread and other baked goods. MyPlate lists the following benefits of eating grains everyday.

⦁Whole grains can reduce the risk of heart disease.

⦁Foods containing fiber, such as whole grains, can minimize or eliminate constipation.

⦁Whole grains can help with weight management.

⦁Grain products fortified with folate, consumed before and during pregnancy, help prevent neural

tube defects during fetal development

Any food made from wheat, rice, oats, cornmeal, barley, or another cereal grain is considered a grain

product. In general, 1 slice bread; 1 cup ready-to-eat cereal; or ½ cup cooked rice, pasta, or cereal is

a 1 oz equivalent from the grains group.

Proteins

Protein foods include nuts, seeds, seafood, meat, poultry, beans, peas, eggs, and soy products.

MyPlate lists the following benefits of eating protein foods every day.

⦁Meat, poultry, fish, dry beans and peas, eggs, nuts, and seeds provide protein, energy, B vitamins (niacin, thiamin, riboflavin, and B6 ), vitamin E, iron, zinc, and magnesium.

⦁Proteins function as building blocks for bones, muscles, cartilage, skin, blood, enzymes,

hormones, and vitamins.

⦁Many protein foods provide iron, which helps carry oxygen in the blood.

⦁Seafood provides omega-3 fatty acids, which can help reduce the risk for heart disease.

How much protein should patients consume each day? MyPlate suggests the following.

Dairy

Dairy includes milk, cream, yogurt, cheese, sherbet, lassi, smoothies, and milkshakes. MyPlate lists the following benefits of consuming dairy products every day.

⦁Improves bone health and reduce the risk of osteoporosis.

⦁Especially important for bone health for children and adolescents because they are building bone mass.

⦁Reduces the risk of developing cardiovascular disease (including hypertension) and type 2

diabetes mellitus.

All fluid milk products and many foods made from milk are part of this food group. In general, 1

cup milk, yogurt, or soy milk; 1 ½ oz natural cheese; or 2 oz processed cheese equals 1 cup from the dairy group

Oils

Oils include canola, corn, cottonseed, olive, safflower, soybean, walnut, sesame, and sunflower oil. Although not exactly a food group, MyPlate lists the following benefits of consuming oils every day.

⦁ Oils provide essential nutrients, including essential fatty acids.

⦁ Oils are necessary for the absorption of fat-soluble vitamins.

Oils are fats that are liquid at room temperature, like the vegetable oils used in

cooking. Because they are liquids, they are measurable in teaspoons. MyPlate notes that some people consume enough oil in the foods they eat, such as nuts and fish. Thus, they would not need to add oil to fulfill daily requirements. For example, 2 tbsp of peanut butter contain about 4 tsp of oil, while half of a medium-size avocado contains

about 3 tsp of oil. MyPlate recommends oils only, not solid fats.

Educating patients about nutrition

When educating about nutrition, consider each patient’s likes and dislikes, cultural traditions for

food, and any health limitations or needs. Also consider each patient’s age, readiness and ability to learn and change, lifestyle, and psychological and socioeconomic factors. It is helpful to set realistic goals, let the patient participate actively in the learning process, and reinforce learning and adherence to dietary modifications. MyPlate (www.choosemyplate.gov) offers informational pages, publications, and online tools for supporting patients in improving their nutritional status. MyPlate also offers materials that can enhance patient education, such as printable handouts and a primer for creating nutrition education materials.

Dietary modifications for specific patient populations

Providers request dietary consultations with nutrition professionals for patients who have various disorders that require dietary modifications. The guidelines for diabetes mellitus, for example, are extensive and beyond the scope of this module. Thus, the following table lists common disorders and brief notes about major dietary guideline

It is also important to understand the dietary modifications for patients who are postoperative and those who have mechanical impediments to regular diets, such as difficulty swallowing.

⦁ Clear liquid: fluids that are transparent or translucent (broth, gelatin, plain tea, apple juice)

⦁ Full liquid: clear fluids plus all juices, milk, ice cream, custard, cooked eggs

⦁ Pureed: any blenderized food that does not contain particles or strands that could trigger choking (blenderized fruits, vegetables, meats)

⦁ Soft: cooked or canned foods (cooked fish that flakes easily, canned fruits); no chewy, stringy, or tough foods

⦁ Mechanical soft: chopped or blended foods that do not require a knife to cut (cooked, chopped cauliflower, soft meatloaf)

DOCUMENTING RELEVANT ASPECTS OF CARE IN PATIENT RECORD

The importance of documentation cannot be understated. Documentation is used for communicating

among the health care team as well as in cases of legal actions. The old saying “If it isn’t charted,

it wasn’t done” is still true. The legal system tends to side with the patient if documentation is not

clearly validated within the medical record.

Documenting the chief complaint

The chief complaint is subjective information that should be described using the patient’s own

words. If the words are exactly as the patient relayed, put them in quotation marks. Use the chief

complaint to further describe what is happening with the patient by using observations, asking

questions, and collecting objective data.

An example of a chief complaint: “I have had a headache for 2 days.”

Documenting procedures

Procedural documentation includes how the patient was prepared for the procedure, the position used, the last time the patient had anything to eat or drink, the procedural process, and how the patient tolerated the procedure. Most of this information is documented by the provider, but the medical assistant documents pre-procedure information (vital signs, informed consent) and postprocedure instructions

Required components of the medical record

Whether the office uses an electronic or paper record, there are specific sections that house the various documents.

⦁Demographic information: This includes name, address, birth date, Social Security number,

phone number, and insurance information. It is important to review this section at each visit to

ensure accurate information for insurance filing and billing, as well as contacting the patient.

⦁Medication record: Review and update this information at each visit. Patients should be asked to bring their medications from home and compare each of them with the medical record. Ask about

over-the-counter medications and supplements as well as any allergies.

⦁Progress notes: This is where the chief complaint or SOAP note that describes each visit can be located.

⦁ Laboratory or diagnostic reports: This section houses laboratory reports and EKG or other

diagnostic tests. Other sections (consultations, problem lists) may be included in the medical record as well. The medical assistant must be familiar with where to locate specific information related to the patient they are caring for. All of these sections should be organized in chronological order, with the most recent reports on top or listed first

Medical necessity guidelines

Medical necessity is used by third-party payers (insurance companies or other entities responsible for payment of medical services) to identify that a specific procedure or test is necessary for the care or diagnosis of the patient. For insurance to cover a specific item, it would need to be deemed medically necessary. This is often seen with hospitalizations, but random tests will not be approved without validation in the medical record supporting the medical need. For instance, an EKG might not be medically necessary for a 30-year-old unless the patient is experiencing chest pain. Documentation is required to support the necessity for the test and for the insurance company to remit pay

Diagnostic and procedural coding

Diagnostic and procedural coding is a universal language of numbers used for billing and reimbursement. Various organizations use this as a means of gathering health data for research and initiatives. Accurate coding maximizes provider reimbursement, but knowingly upcoding (coding for more than what was performed) for a higher reimbursement can lead to fraud and legal action against the provider.

ENSURE PATIENT SAFETY IN THE CLINICAL SETTING

The importance of physical safety in the ambulatory care setting cannot be understated. Take every effort to maximize the safety of patients and staff to prevent injury and avoid litigation. Plan for other considerations, such as fires and natural disasters, to protect human life. This involves preparing emergency policies and evacuation plans and having emergency equipment easily accessible.

Safety concerns

Avoid cluttered hallways, spills, items on the floor, furniture with sharp corners, restricted

doorways, and dimly lit areas in a medical facility. Using floor signs, cleaning spills immediately, strategically arranging furniture, and avoiding loitering in hallways assist in accident prevention. The medical assistant is responsible for helping maintain safety in the office. Resolve safety concerns promptly or report them to the proper authority. Contractors often maintain most of the external environment, but the medical assistant should report sidewalk cracks, loose handrails, snow, or ice to their immediate supervisor

Safety adjustments for specific populations

Pay particular attention to safety for pediatric patients, older adult patients, and those who have specific needs. Children are prone to injuries by falling on sharp objects, choking on items in a waiting room, or touching electrical sockets. When preparing the patient prior to being seen by the provider, take precautions to avoid a child falling from the examination table. Maintain visual and physical contact with patients until they are returned to their parent or guardian. Older adult patients or patients who have disabilities can need assistance with walking or getting onto an examination table. Some patients might also need supervision while waiting to be seen. Bathrooms should be equipped with emergency alert buttons; if they aren’t available and there is a safety concern, someone should be with or near the patient. Regardless of patient age or condition, always be alert for potential hazards and take measures to maximize patient safety.

Specialty examinations

Specialty exams depend on services provided by the provider and the availability to provide

these services. Gynecological examinations, allergy tests, and cardiac stress tests are some of the procedures with which a medical assistant might need to assist.

FIRST AID AND BASIC WOUND CARE

The goal of providing care in an emergency is to stabilize the patient and prevent further injury.

When administering first aid, the use of PPE is imperative

Types of tissue injuries

Wounds can be open (the skin is broken) or closed (there is no break in the skin). For any open

wound, the tetanus immunization status must be obtained for the provider to determine the

appropriate treatment. The following are some common types of injuries in the clinical setting

Types of limb injuries

Mild to moderate injuries to the extremities are common in an ambulatory care setting. Medical

assistants need to be familiar with the more common types of injuries to the limbs to assist the provider with these patient conditions. The following are some common types of injuries occurring

Other types of emergencies

In the event of a medical emergency, the medical assistant must be prepared to react and respond appropriately while assisting the provider with treatments or medication administration. General guidelines for identifying and responding to each emergency are listed in the following table

Wound care follow-up

Wounds can be open or closed, intentional through surgical intervention, or accidental through trauma. Wounds heal based on location, mode of injury, available blood supply, and the patient’s general health status. The medical assistant is often responsible for patient education regarding the healing process of a wound. Making sure the patient understands the importance of notifying the provider if infection is suspected is a crucial part of this education

Signs of infection

Typical signs of infection include the following.

⦁ Redness and swelling at or

around the site

⦁Feeling hot to touch

⦁Drainage (other than clear)

⦁ Foul odor from the site

⦁ Fever

⦁ Malaise

⦁ Red streaks extending from

the wound (lymphangitis)

Changing a sterile dressing

In preparation for a dressing change, the medical assistant should wash their hands using proper hand hygiene prior to donning sterile or non-sterile gloves. The use of sterile gloves is uncommon but should be considered if contact with underlying tissues is anticipated. For dressings that are stuck to the wound, soak the dressing in sterile saline or sterile water prior to removal. Always take precautions to prevent further contamination of the wound when conducting a dressing change. Remember that dressings are sterile and bandages are nonsterile. Dressings cover wounds and bandages cover dressings. When changing a dressing, discard all waste contaminated with body fluids in a biohazard container. When applying medications to the wound, use an applicator and avoid touching the tube or container to the wound. Do not re-insert an applicator into a medication container once used. Open dressing packages without touching the contents. When grasping a dressing, touch only the edges that will not come in contact with the wound. Once the wound is covered, a bandage or tape can be applied

ASSISTING PROVIDERS WITH EXAMINATIONS AND PROCEDURES

General physical exams

The medical assistant is responsible for preparing the patient for the examination and assisting the provider as necessary. A medical assistant uses critical thinking skills in determining how to properly prepare the patient for the exam, what equipment needs to be prepared, and what supplies are needed

Positioning and draping requirements

The medical assistant prepares patients for examinations and procedures based on the reason for the visit. Patients are not usually placed in specific examination positions until the exam is conducted. However, advance preparation that includes patient instructions and appropriate disrobing saves time when the provider is ready to perform the procedure.

Positioning is based on the reason for the visit and the general physical condition of the patient. A patient who is experiencing orthopnea might need adjustments in the usual positioning for a particular exam. A patient who is unstable might need to wait to get on the examination table until the provider is present. Protecting patient privacy through proper draping is also important. Provide a gown, cape, or drape if disrobing is required.

Assisting the provider during an exam

The provider might be able to conduct the examination without assistance. Sometimes the medical assistant is needed as a chaperone, especially during female examinations. Holding an uncooperative child can be necessary so that an examination can be safely performed. The medical assistant can also serve as the nonsterile circulating staff for procedures such as suturing, which can include setting up and adding items to a sterile field. During a pelvic examination, the medical assistant might need to hand the provider instruments and receive specimens obtained during the examination

REVIEWING DISCHARGE INSTRUCTIONS WITH PATIENTS

When patients are under stress, they often do not comprehend all instructions from the provider. Provide written instructions whenever possible. Review all instructions with the patient and answer questions prior to their departure.

Reviewing discharge instructions or plan of care

Discharge instructions or the plan of care after any visit in the ambulatory care setting includes

the following.

⦁Activity restrictions: This includes bathing and exercising.

⦁Diet restrictions: It is unlikely to have dietary restrictions following minor ambulatory surgery.

However, in cases of abdominal pain, diarrhea, or vomiting, a liquid diet with progress as tolerated

may be recommended.

⦁Wound care: This includes instructions such as changing the dressing, applying medications to the wound, and observing for signs of infection.

⦁Medications: If the patient has prescriptions for medications such as antibiotics, instruct the

patient on how and when to take the medication, how it should be stored, and possible side effects.

⦁Follow-up appointments: This includes when to return to the office and how to contact the office if an unexpected event occurs.

Setting up referrals

The primary care provider might need to elicit an opinion from a specialist, or the patient might

need to be referred for procedures or treatments not available in the office. Ensure that the referral process is handled as smoothly and efficiently as possible. Obtain the necessary information from the patient (available days and times, contact numbers) and confirm insurance information. In addition, determine what preparations are needed for the appointment and provide that information to the patient

Precertification of procedures

For some insurance providers (especially managed care plans) to cover expenses associated with diagnostic or therapeutic procedures, precertification may be required. It is always advisable to have the patient contact their insurance provider to confirm coverage, but the medical assistant might also need to provide referral information to the insurance provider for approval prior to scheduling the appointment.

Participating providers

Some diagnostic procedures, such as a chest x-ray, do not require precertification. However, patients might receive a greater coverage of expenses if they seek services from a provider who participates with their insurance plan. The medical assistant should be familiar with the insurance plan and inquire about participation with the plan when scheduling an appointment. If the patient can schedule the appointment on their own, educate them to confirm that the provider is participating in the insurance plan to maximize coverage.

Following up with the patient

With the implementation of the Affordable Care Act, the medical assistant often acts as the patient navigator or case manager. This means that the care is all-encompassing and delivery is not simply at the office level. It is important to have a follow-up conversation with the patient to see if they kept their referral appointment. If treatments were carried out in the office, a follow-up call can ensure that the patient understands and is following instructions delivered by the provider

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

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 health care professionals.

Temperature

Measuring temperature is actually determining the relationship of heat production and heat loss in the body, also referred to as metabolism. The most common cause of

pyrexia, or fever, is infection. Fever is the body’s natural defense to fight invasive organisms and is therefore a normal reaction to illness. Patients who have a fever can present with chills, anorexia, malaise, thirst, and a 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). 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 the particular circumstance.

⦁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, pulse can be determined through

auscultation. The apical pulse is counted by listening to the heart beat at the apex of the heart. Auscultation is also incorporated when taking a 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 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

Respiration

Respirations are evaluated on rate, rhythm, and depth. 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 averages 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 phase 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 play 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

ABNORMAL SIGNS AND SYMPTOMS

The medical assistant is responsible for obtaining assessment results and communicating abnormalities to the provider. Expect to perform most of these skills during the intake process. The usual process for obtaining intake information is to first record the chief complaint and weight. Take vital signs in the order they are charted: temperature, heart rate, respirations, and blood pressure. Other skills tests are completed based on the reason for the visit and the particular patient. Clearly document intake information in the medical record and alert the provider of any abnormal results prior to them seeing the patient

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 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 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 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 a 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 an 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 pick-up and disposal

of biohazard material from medical facilities. These agencies

also must abide by OSHA standards regarding biohazard

material handling and disposal

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. Patient and providers can underestimate the language barrier. Cultural differences are also a barrier; culture affects understanding of a word or sentence and even 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 health

PATIENT PRIVACY AND CONFIDENTIALITY

Patient privacy should be a priority for health care staff at all times. This includes the use of a fax machine, copy machine, or email.

⦁Never leave confidential patient information on a fax machine.

⦁Always use a cover page.

⦁ Verify the correct fax number.

⦁ Shred medical documents when necessary.

⦁ Be sure the fax machine, copier, and computer are not visible to patients.

The medical record contains sensitive information about the patient history, current health status, and planned treatment. Never release this information to anyone without the patient’s written consent, unless it is legally required through a subpoena. A subpoena is a written order that commands someone to appear in court to give evidence. If a legal case is presented and a medical record is subpoenaed, be sure to only release the requested information.

Laws that affect medical records

HIPAA

HIPAA gives patients rights over their health care information. They have the right to get a copy

of their information, ensure the medical record is correct, and know who has had access to the

record. Covered entities that must adhere to HIPAA include health plans, providers, and healthcare

clearinghouses. If a covered entity engages a business associate to provide health care functions,

the covered entity must have a written business associate contract or other arrangement with the

business associate that establishes in detail what the business associate has been requested to do

and requires the business associate to comply with the HIPAA requirements to protect the privacy

and security of protected health information. In addition to these contractual obligations, business

associates are directly liable for compliance with certain provisions of the HIPAA rules.

HIPAA requires providers to explain patient rights. The law requires patients to sign a form

indicating they have received a privacy notice from a doctor, hospital, or other provider. HIPAA

requires written consent when sharing health care information. HIPAA does not require a

provider or health plan to share information with a patient’s family or friends, unless they are the patient’s personal representatives.

HITECH Act

The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 was created to improve health care quality, safety, and efficiency for information technology and electronic health records. The HITECH Act provides barriers to information exchange. The act dictates nationwide use of health information technology to encourage an effective marketplace, improved competition, and consumer choice

Medical record storage and retention laws

The medical record contains documented medical information that may be used for many different reasons. Accurate documentation in health care is critical. The record is used to manage health care

and acts as a legal document. The record must be stored and retained in compliance with state laws that will differ for each state. HIPAA requires that documentation be retained for a minimum of 6 years. However, some states require a longer period. In this case, state law overrides federal law

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 assistants’ 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 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