This edition of Clinical Procedures for Medical Assistants continues to provide clear, concise, step-by-step instructions on more than 200 of the most commonly performed medical office procedures.
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This manual is designed to acquaint you with some of the routine procedures medical assistants may be asked to perform in an outpatient setting. While all safety and infection control guidelines must be followed, remember that each physician has unique preferences for how tasks are completed. Do not hesitate to ask the physician or office manager if you have any questions regarding specific protocols.
In this manual, you will find detailed, step-by-step instructions for many of the most common procedures performed by medical assistants, including:
-Patient intake and history
-Assisting with examination and treatment
The Clinical Role of the Medical Assistant
Most people think of medical assistants as the ones who take your blood pressure or collect your urine sample at the doctor’s office. But medical assistants (MA) actually do much more than that. They are an important part of the healthcare team, working alongside physicians, nurses, and other allied health professionals. It is a demanding job that requires both clinical and administrative skills.
Medical assistants perform many duties in a variety of settings, including doctor’s offices, clinics, hospitals, and even research laboratories. Their duties vary depending on the size and location of their employer, but they typically fall into one of two categories: clinical or administrative. Clinical duties include taking patient histories, performing physical exams, and assisting with procedures. Administrative duties include answering phones, scheduling appointments, and handling billing and insurance paperwork.
While most medical assistants have at least a high school diploma or equivalent, some employers prefer to hire those with formal training from an accredited MA program. There are over 300 MA programs across the country that range in length from 9 months to 2 years. Many community colleges offer affordable MA programs that can be completed in a short amount of time.
Patient Preparation for Clinical Procedures
Patient Preparation for Clinical Procedures:
The medical assistant must have a thorough understanding of the purpose and importance of the clinical procedures performed in the office or clinic setting. It is essential that the patient be prepared physically and emotionally for these procedures. The medical assistant plays an important role in preparing the patient, both physically and emotionally.
Physical preparation includes such things as fasting prior to a laboratory procedure, withdrawal of medications that may affect the test results, and abstaining from smoking before a bronchoscopy. Emotional preparation includes educating the patient about what to expect during the procedure, providing support and reassurance, and answering any questions the patient may have.
Infection Control in the Clinical Setting
As a medical assistant, it is important that you are aware of the importance of infection control in the clinical setting. There are a number of ways to help prevent the spread of infection, and it is important to be familiar with these procedures.
One of the most important things you can do to prevent the spread of infection is to practice good hand hygiene. This means washing your hands thoroughly and often, and using alcohol-based hand sanitizer when soap and water are not available. You should also avoid touching your face, and clean any surfaces that may have come into contact with body fluids or secretions.
It is also important to wear proper protective gear when working with patients. This includes gloves, gowns, masks, and eye protection. These items should be removed and disposed of properly after each patient encounter.
You should also be aware of the symptoms of common infections, so that you can identify them early and take appropriate steps to prevent their spread. These steps may include isolation of affected patients, increased hand hygiene, and use of protective gear.
Taking and Recording Patient Vital Signs
Clinical Procedures for Medical Assistants, 9th Edition provides clear, step-by-step instructions for more than 140 medical assisting procedures.
In this book, you’ll learn how to take and record patient vital signs, which include temperature, blood pressure, pulse, and respiratory rate. You’ll also find information on measuring body weight and height, as well as performing urine dipstick testing. Additional topics include performing electrocardiography (EKG), phlebotomy, preparing patients for exams and procedures, and infection control.
Assisting with Patient Examinations
As a medical assistant, you will be expected to play a vital role in assisting with patient examinations. This includes everything from setting up the examination room to taking vitals and collecting specimens. Clinical procedures for medical assistants can vary depending on the state in which you are working, but there are some basic guidelines that will always apply.
Before the physician or other healthcare provider arrives, it is your responsibility to ensure that the examination room is clean and ready for use. This means making sure that all of the necessary equipment is in place and that any blood or other bodily fluids have been cleaned up. Once the patient arrives, you will need to take their vitals, such as their blood pressure, temperature, and heart rate. You may also be responsible for collecting specimens, such as urine or blood samples.
During the examination itself, you will need to assist the provider as needed. This may involve holding instruments, handing them items, or providing instruction to the patient. After the examination is complete, it will be your job to clean up the room and make sure that all of the equipment is properly sterilized. You may also need to provide post-examination care to the patient, such as bandaging a wound or applying ice to an injury.
Collecting and Processing Laboratory Specimens
Collecting and Processing Laboratory Specimens
One of the most important roles of the medical assistant is assisting with laboratory procedures. This involves not only understanding how to collect various types of specimens, but also how to process them properly. Improperly collected or processed specimens can result in false test results, which can be detrimental to a patient’s health.
There are four main types of laboratory specimens: blood, urine, stool, and cerebral spinal fluid (CSF). Each type has its own set of specific collection and processing procedures that must be followed in order for the specimen to be usable.
Blood specimens can be divided into two categories: those that require special collection techniques, such as venipunctures, and those that do not, such as fingersticks. The most common type of blood specimen is the venipuncture, which is used to collect both whole blood and serum. In order to properly collect a venipuncture specimen, the medical assistant must first select the correct size needle and antiseptic swab. The size of the needle will depend on the amount of blood being collected; for example, a 3-mL specimen requires a 21-gauge needle, while a 10-mL specimen requires a 18-gauge needle. After selecting the correct size needle, the medical assistant must then swab the injection site with an antiseptic solution in order to disinfect it. Once the site has been disinfected, the medical assistant can then proceed with collecting the specimen.
Urine specimens can either be collected via voiding or catheterization. Voiding is when the patient urinates into a cup or other container; this method is generally used for urine screens or dipstick tests. Catheterization is when a catheter is inserted into the patient’s bladder in order to collect a urine sample; this method is generally used when a more detailed analysis of the urine is needed (e.g., culture and sensitivity). No matter which method is used to collect the urine specimen, it is important that it be done in a clean environment in order to avoid contamination.
Stool specimens can be collected via three methods: direct plating, fecal occult blood testing (FOBT), or stool guaiac testing (also known as fecal immunochemical testing or FIT). Direct plating involves taking a small sample of stool and placing it directly onto an agar plate in order to grow bacteria for identification purposes. FOBT uses chemical reagents that change color when they come into contact with blood in stool; this method is used as a screening tool for colorectal cancer. FIT uses antibodies that bind specifically to human hemoglobin; like FOBT, it too is used as a screening tool for colorectal cancer. As with urine specimens, it is important that stool specimens be collected in a clean environment in order to avoid contamination.
CSFSpecimens are generally only collected via lumbar puncture (LP), also known as spinal tap; this procedure involves puncturing the dura mater surroundingthe spinal cord in order to withdraw CSF for analysis purposes. due tothedangerous natureofthis procedure,it should onlybe performed bya qualifiedhealthcare professional(e.g., physician).
Performing Basic Laboratory Procedures
In this chapter, you will learn basic laboratory procedures that you may be called upon to perform as a medical assistant. You will also be introduced to some of the common laboratory tests performed in a physician’s office, clinic, or hospital. Many of these tests require special training and certification, which you will receive in your externship. The procedures in this chapter are ones that you can perform after completing your training.
Before starting any procedure, review the physician’s order and become familiar with the test to be performed. Make sure you have all the supplies you need and that they are within easy reach. Be sure to read the manufacturer’s instructions for any equipment you are using. If you have any questions, ask the lab supervisor or another experienced medical assistant for help.
Administering medications is one of the most critical clinical procedures medical assistants perform. It is also one of the most regulated, with state and federal laws and agency guidelines dictating everything from who can perform the procedure to how it must be carried out. The Ninth Edition of Clinical Procedures for Medical Assistants provides clear, step-by-step instructions on more than 50 of the most commonly performed medical assisting procedures, along with rationales, tips, cautions, and advanced considerations. Updated to reflect the latest thinking in evidence-based medicine, safety, and infection control, it includes new information on electronic health records, medications administration via fax/phone orders, and point-of-care testing sites.
Assisting with Minor Office Surgery
Minor office surgery is generally performed on an outpatient basis, which means the patient goes home the same day. Usually, local anesthesia is all that is necessary. The physician or surgeon will numb the area to be treated with a topical anesthetic, an injection of local anesthesia, or a combination of both. The medical assistant’s responsibilities before, during, and after minor office surgery vary depending on state law and regulation, as well as on the physician’s or surgeon’s preferences.