1. Clinical -back office
-patient screening
-recording vital signs
-assist with surgical procedures
-physical examinations
-prep patients for
... [Show More] surgical procedures
2. Administrative -front office
-scheduling appointments
-medical coding
-medical billing
-manage physicians schedules
-opening and closing clinic
3. Licensure a state requires a person to obtain a license to practice in the state
4. Certification individuals become certified when they pass a written
exam administered by an accredited organization
5. Registration individuals become registered when they pass a written exam administered by an accredited organization
6. Qualities of a Medical Assis- tant
-communication skills
-empathetic and compassionate
-positive attitude
-physical appearance
-ethical behavior
7. AAMA American Association of Medical Assistants
-provides CMAs with the information to obtain their CEUs
8. CMA Certified Medical Assistant
-valid for 5 years
-during that time the CMA is expected to complete their CEUs
9. CEU Continuing Education Units
-CMA is expected to complete 10 points in administrative,
clinical and general areas
and 30 points from a combo of all
10. AMT American Medical Technologists
-provides RMAs with the information to obtain their CCP credits
11. RMA complete 30 points within their CCP every 3 years to
remain a RMA
12. CCP Certification Continuation Program
13. NCCT National Center for Competency Testing
-provides information for NCMAs to obtain their CEUs
14. NCMA Nationally Certified Medical Assistant
-complete 14 hours of CEUs every year
15. Patient Care Greet patient with your first name and inform him or her that you will be assisting in care. Properly identify patient before providing care. Called for patient First and Last name then confirm patient identity with D.O.B.
16. Purpose of Recording a Pa- tient's Medical History
17. Forms that Pa- tient Must Fill Out
-allows for quicker diagnosis and treatment
-what treatments work best on the patient
-research and public health purposes
-basis for insurance claims
-Demographic Data: form containing patient contact info, SSN, and insurance provider details
-Financial Policy Form:form that explains their billing poli- cies
-HIPAA:(The Health Portability and Accountability Act of 2004 form)includes notice of a provider's privacy policy
-Release of Medical Information Form:patients are re- quired to sign a form authorizing the provider to release their medical records
18. -Cheif Complaint:the reason for the patient's visit in his or her own words
Components of a Complete Med- ical History
19. Patient Intake In- terview
20. Rules for docu- menting in a pa- tient's chart
-History of Present Illness:length of time that the patient has been experiencing the complaint, description of the complaint, and any known injuries
-Medical History:patient's medical history, diagnosis, surg- eries, medications, and allergies
-Family History:this includes any family history of illness of parents, grandparents, and siblings
-Social History:This includes the patient's alcohol con- sumption, smoking, exercise, and stress levels
-Review of Systems:this step is when the physician com- pletes examining the patient from head to toe
-Exam room is clean
-Review patient's chart
-greet patient sing his or her first name and request verifi- cation of his or her date of birth
-make patient feel comfortable and ask why they are here today
-listen
-ask variety of questions to get more details regarding the complaint
-once documentation is complete, check vital signs and prepare the patient for the examination per the physician's orders
-blue or black ink
-date and time every entry
-leave no space between entries
-do not erase entry. instead make line through mistake and correct and initial
-sign entry with first initial and full last name with creden- tials
-use universal accepted abbreviations
-never leave chart open
21. SOAPER -Subjective
-Observable findings of the complaint
-Assessment
-Plan for treatment
-Educating the patient
-Response
22. CHEDDAR -Cheif complaint
-History
-Examination
-Details of Complaint
-Drugs and Dosages
-Assessment
-Return Visit if Needed
23. CDC The Centers for Disease Control and Prevention
24. Average Body - 98.6 *F or 37.0 *C
Temperature
25. Afebrile - the patient has no fever. the body temp is in the normal
range
26. Febrile - patient has fever. temp above normal range.a temp at
100.4 degrees fahrenheit is considered being febrile or
having a low grade temp
27. Lysis - when temp slowly returns to normal after a period of fever
28. Crisis - when temp suddenly returns to normal
29. Intermittent - fever varies and then returns to normal followed by a
phase of increased temp
30. Remittent - fever when body temp keeps varying and does not return
to normal
31. Continuous - fever remains constant above baseline
32. Tools Used to *Oral-Digital, non mercury glass or paper thermome-
Measure Body ter.(mouth)
Temperature *Aura/Tympanic-digital thermometer(ear)
*Rectal-digital or non mercury thermometer(rectum)
*Temporal-digital thermometer(forehead)
33. What is a pulse?the pulse rate of an in- dividual is one
*Axillary-digital or non mercury thermometer.axillary area(armpit)
Radial Pulse-most common pulse site(wrist)
Carotid Pulse-mainly used during emergency(front of neck)
Brachial Pulse-most commonly used to obtain blood pres-
complete cycle of sure measurement(inner part of the elbow)
contractions and relaxation of the heart Temporal-temple Femoral-groin Popliteal-behind knee Dorsalis Pedis-foot
Apical-heart(fifth intercostal space on the chest)
34. Normal Pulse Rate *Adults-between 60-100 beats per min
*Children-between 120-170 per min
35. Normal Respira- tion Rate *Adults 14-20
*Newborn 30-60
*Infants 24-40
*Children 22-34
36. Pulse Oximeter -placed on finger or earlobe. measures oxygen level in the patient's blood and generally gives the pulse rate
37. Sphygmo- manometer -measures blood pressure. should be placed 3 inches above antecubital space
38. Stethoscope -take blood pressure and apical pulse on a patient
39. Normal Blood Pressure *Adults-systolic less than 120 over diastolic less than 80
*Children-systolic less than 100 over diastolic less than 65
*Adolescents-systolic less than 118 over diastolic less than 75
40. Hyperten- sion(HTN) -140/90(high blood pressure)
41. Prehypertension -systolic 120-139 over diastolic 80-89
42. Six Methods
Used to Examine the Body *Observation
*Palpation
*Percussion
*Auscultation
*Mensuration
*Manipulation
43. Observation -changes into skin color, rashes or anything unusual that indicates they need further investigation
*Otoscope: look into an ear
*Ophthalmoscope: look into eyes
*Pen Light: look into throat
44. Palpation -examining using touch. feel a specific body part or organ for size and condition
45. Percussion -tap a part of the body using their fingers or a hammer. produces either a hollow or dull sound depending on the presence of air in the organ. used to check liver or kidneys.
46. Auscultation -listening to the body sounds using a stethoscope. used to listen to lungs, abdomen(intestines) and heart
47. Mensuration -measurement. used to measure height, weight or chest circumference
48. Manipulation -to check range of motion flex or move a joint. used to evaluate pain in the joints, tendons, and or muscles
49. Supine Position -lying on back. used to examine anterior surface of the body from head to toe
50. Dorsal Recum- bent -lying on back, legs separated and feet flat. used during rectal, abdominal and genital examinations
51. Sims -lies on left side, left knee slightly flexed and right sharply flexed. vaginal and rectal exams
52. Fowlers
-sits resting against table at a 90 degree angle: high
fowler's position or at a 45 degree angle: semi fowler's position
53. Lithotomy -lies on back, butt close to edge of table, feet in stirrups.
pelvic rectal stirrups
54. Prone -facedown. examine back and spine (posterior part of the
body)
55. Knee chest -face down butt up
56. Sequence of *Head and neck(eyes, nose, and throat)
Physical Exami- *arms and hands
nation *chest and lungs
*heart
*breasts
*abdomen
*genitalia and rectum
After a Physical Examination
*paperwork
*tests
*injections
*draw blood
*send blood to lab
*document
*clean exam room [Show Less]