By: Kiana Murdock

Academy of Health Professions Level Two

Medical Assistants are becoming a key element to many healthcare practices as the need

for support personal increases. They work as part of a healthcare team to provide the patient with

the best possible care. The duties of a medical assistant can vary based on the size and needs of

the healthcare practice. These general duties can include having good verbal and nonverbal

communication, explaining treatment procedures to patients, providing patient education within

scope of practice, facilitating treatment for various types of patients, acting as a patient advocate,

and maintaining medical records. Medical assistants can work in an administrative, clinical, or

laboratory environment which can require the use of more advanced skills.

As a medical assistant working in an administrative position this means one may handle

the payroll, obtain equipment, and be the voice between the physician and pharmaceutical and

medical supplies representative. Also one will schedule appointments, answer telephones,

perform medical transcription, arrange for hospital admission, handle billing, book keeping, and

insurance processing.

In a clinical environment medical assistants must be able to perform a different range of

skills. These skills can include assisting the doctor during examinations, assisting with asepsis,

infection control, perform diagnostic test, give injections, perform phlebotomy, dispose of soiled

or stained supplies, perform first aid, prepare patients for examinations, preparing and

administering medications as directed by the physician, recording vital signs and medical

histories, removing sutures or changing dressings on wounds, sterilizing medical instruments,

instructing patients about medications and special diets, assisting minor surgeries, and teaching

patients about special procedures before laboratory tests, surgery, x-rays, or ECG's.
 When a medical assistant is working in a laboratory environment they must perform

another range of laboratory skills. This skills can include performing Clinical Laboratory

Improvement Amendments, collecting, preparing, and collect specific specimens properly,

arranging laboratory specimens, teaching patients to collect specific specimens properly, arrange

laboratory services, meet safety standards and fire protection mandates.

Having a good understanding of the duties and responsibilities of a medical assistant can

create a better environment for the patients to receive care and the healthcare professionals to

give the care needed. One can gain their medical assisting CMA credential through the

Certifying Board of the AAMA. The American Medical Technologist organization also gives

credentials as Certified Medical Assistant Specialists. Both of these programs required

participation in an accredited program and distinct areas of knowledge to pass their

examinations.
 Legal and Ethical Issues

Just as any other healthcare professional it is important for medical assistants to know

and understand medical laws, ethics, and the Health Insurance Portability and Accountability

Act. As a medical assistant one must know the basic information about medical law and ethics to

help one understand different perspectives. This can include the rights, responsibilities, and

concerns of healthcare consumers; one must understand how law can affect their profession and

the patients. The legal and ethical issues facing society, patients, and healthcare professionals as

the world change.

Although there are public laws there are two types of laws that apply to healthcare

practitioners, these are criminal law and civil law. Criminal law is a crime against the state or

federal government that can include a felony or misdemeanor. Civil law involves crimes against

a person, often resulting in someone getting sued. Under civil law falls tort, this is a civil wrong

doing committed against a person or property that resulted in physician injury or damage to

someone's property or that deprives one of his or her personal liberty and freedom.

Both patients and medical professionals have rights and responsibilities that must be

recognized and respected. As a medical assistant one has a general liability in the duties they

perform and must understand the standard of care and the duty of care. They must also

understand the patient's rights and responsibilities as they are the patient's advocating voice.

Medical assistants must fulfill the standards of medical the medical assisting profession

by practicing the legal concepts for the profession. These legal concepts should be upheld;

maintaining confidentiality, practicing within the scope of training, preparing and maintain

medical records, documenting accurately, using appropriate guidelines when releasing

compliance with government guideline, following established risk management and safety

procedure, and meeting requirements for professional credentialing.

Malpractice is the improper, illegal or negligent professional activity or treatment by a

medical practitioner. There are four D's of Negligence these are duty which the patients must

show that the physician owed the patient a duty, derelict which the patient must show that the

physician failed to comply with the standards of the profession, direct cause which the patient

must show that any damages were a direct cause of the physician's breach of duty, and damages

which the patient must show that they suffered injury. Malpractice is a major issue but can be

prevented, there are four C's which should be followed for malpractice prevention. These include

caring, communication, competence, and charting. Knowing all the laws and ethics can help one

be a better medical assistant.

There are many situations that can occur and any time. Having a plan can prevent

confusion and minimize risk to patients, physicians and staff by creating a safe environment in

the healthcare setting. Plans should be created fir OSHA Hazard Communication, electrical

safety, fire safety, emergency action plan, chemical safety, blood borne pathogen exposure,

personal protective equipment, needle stick prevention. The Occupational Safety and Health

Administration regulate the safety standards to protect employees safety in the workplace. Each

facility should also have their own plan set in place in case of emergency including fires and

transmissions. There can be multiple ways of transmission that can include airborne, blood

borne, foodborne, and vector-borne. Having good infection control and reporting of certain

diseases to the CDC can help keep the facility, its workers and its patients in good health.
 Patient Reception

The reception area is the first reflection of an office that a patient sees. This can create the

facultys first impression. Having a good patient reception area ensures that the patient has a

pleasant and comfortable experience while they wait to have care. There can be many details that

influence the feeling of the patient reception area this can include dcor, furnishings, lighting,

room temperature, magazines, bulletin board, televisions, and cleanliness. When creating a

patient reception they must keep in mind patients with special needs. There should be

handicapped parking, wheelchair ramps, braille and other facility accommodations as the

American with Disabilities Act outlines.

The look of the patient reception area is important but the staff working in that area is a

key to the functioning of the healthcare facility. The person working at the front desk is called

the receptionist, their main job is to greet people, register them, give them direction, and answer

the phone. Another important duty of the receptionist is collecting payment and observing the

patients sitting in the main reception area.

Opening and closing the office is often a responsibility given to the receptionist. When

opening, one should arrive thirty minutes prior to the scheduled time for offices operations to

begin. First priority is to check the answering machine to check for staff and patient delays,

cancellations, or concerns. When closing the office one must turn off equipment, check exam

rooms to make sure supplies are stocked, clean the reception are, ensure laboratory specimens

are placed for pick up, and activate the security system.
 Office Equipment and Supplies

There are many different types of administrative equipment that is required for a medical

office to function effectively and smoothly. It is the medical assistant's job to learn how to

evaluate, purchase or lease, operate, and maintain this equipment. The use of application

software can be an essential skill to a medical assistant as it can increase the efficiency and speed

of the work being done.

Application software can include database management the databases are used to store

patient records that can include billing information, medical chart date, and insurance company

facts. The application software can also include appointment scheduling that can allow one to

enter patient preferences, and also electronic transactions can be done via application software.

Although electronic awareness is important a medical assistant must also take the

responsibility of maintaining supplies. Accurate inventory and ordering proper supplies can be

crucial to the facility. The medical assistant must check supplies each time they are in the office

and record supplies on an inventory card. They must than order the supplies by completing

paperwork, checking orders received, correcting errors in shipments, and making payment.
 Examination and Treatment Areas

An exam room is an area where the physician observes the patient, listens to the patient's

description of symptoms, performs a general physical exam, and dispenses treatment. The care of

the medical office's exam room is the responsibility of the medical assistant; this can include

preparing equipment and supplies. The equipment and supplies must always be cared for with

proper infection control.

To maintain infection control and prevent the spread of pathogens specific sanitation and

disinfection must be performed. Sanitization is the scrubbing of instruments and equipment with

special brushes and detergent to remove blood, mucus, and other contaminants where pathogens

can grow. Some equipment must have sterilization which is the complete destruction of all living

organisms while others just need disinfection. Disinfection is the process that destroys most

microorganisms but cannot kill all microorganisms, bacterial spores and certain viruses can

survive most disinfection.

All surfaces on the examination room should be disinfected, keep the examination table

clean, making hand hygiene a priority. The examination room should have a temperature at 72

degrees Fahrenheit; lighting should be good and also have good air ventilation. Each

examination room should have general supplies including an endoscope, exam light, laryngeal,

nasal speculum, ophthalmoscope, otoscope, penlight, reflex hammer, sphygmomanometer,

stethoscope, thermometer, tuning fork, cervical scraper, and vaginal speculum. Certain tools

need to be sanitized, disinfected, and sterilized. An ophthalmoscope, otoscope, penlight, reflex

hammer, sphygmomanometer, stethoscope, tape measure, tuning fork, laryngeal mirror, and

nasal speculum must all be sanitized and disinfected. While and anoscope, curette, needle,
syringe, and vaginal speculum must be sterilized. The look and feel of the examination and

treatment areas is important to make the patient feel comfortable and safe.

Written and Electronic Documents

In today's business environment most communication is done through electronic emails

and documents. The skill demonstrated in the creation of a simple business document reflects on

the medical skills of the physician and the practice. Written documents are also legal records so

all electronic and written papers must be prepared properly and carefully. There are important

things each letter should have including letterhead paper, envelopes, labels, invoices, and

statements.

The letterhead paper should have the physician name or practice and address printed

along the top, along with the names of the associates in the practice. The letter head is important

but the content within the letter is the key to effective communicating with the patient. The

purpose of the letter and whom it is being written for should be clear and concise. There should

be clarity in the writing and appropriate style. The letter should always be proofread and edited

before sent off. Make sure to properly address and stamp each letter so it can be sent to the right

place and received promptly.

A major role of a medical assistant is documenting and maintaining patient medical

records. There are many documents included in patient medical records that include personal

information or data, physical and mental conditions, medical history, current medical care, and

future medical care if the patient is referred to other physicians or testing. Patient records serve

dual roles as communication tools and legal documents. The patient has control over who can see

and access their medical records. All medical records should include the patient's address and

phone number, occupation, medical history, current complaint or condition, healthcare needs,

medical treatment plan or service received, radiology reports, laboratory reports, and response to

care.

Medical records are very important as legal documents. If something has not been

documented then there is no proof that the event took place. The medical records can be used to

court cases in defense for the patient or doctor and must be retained for seven years. All medical

care, evaluations, and instructions the physician gives to the patient must be documented. Every

document must be clear, accurate, legible, dated, signed and written in blue ink. When a patient

refuses treatment it must also be documented, the term for that is noncompliant. Patient records

can be used to educate patients about their own conditions. They can also be used to evaluate the

quality of care and treatments a facility provide and they are an important part of medical

research.

Basic information must be acquired of all patients seen in a medical practice. When

coming to a new medical practice a registration form must be filled out to obtain basic

information this can include patient's legal name and physical address, phone numbers, date of

birth, medical insurance, emergency contact name, and primary care physician. Patient's medical
history is also very important for the medical file. It contains patient's past illnesses, surgeries,

known allergies, and current medication.

Electronic Health Records

An electronic medical record is an electronic record of health-related information for an

individual patient that is related, compiled, and managed by providers and staff members located

within a healthcare organization. There are many advantages to electronic records such as the

ability to easily share patient information and report quality measures and public health

information. Also electronic records have the ability to save paper and money for the

organization. They are more efficient to store and increase the legibility of charts and transfers.

Electronic medical records documents are legal documents and once the information has

been saved on them is cannot be changed. Before saving information one should double check

everything that is being documented. If there is an error it should be noted and reported as soon

as possible. Electronic records can allow staff to easily attain verification of the patients

insurance coverage before a procedure and help with automatic billing to patients. Not only do

electronic medical records help facilities but also the patients. Patients can easily access their

information and communicate with their healthcare providers. They can order prescriptions

electronically and be updated on future appoints and tests.

help millions, this information must still be confidential and secure. There should be individual

access codes and passwords for each person. When a healthcare provider enters a patients

electronic medical record their initials, time, and date should be recorded in the medical record.

HIPPA is in place no matter the medical record and documentation being used.

Patient Interview and History

As a nursing assistant you are the first contact with the patient therefore your attitude can

create the perception of the medical office. Conducting the patient interview and recording the

necessary medical history are essential to the medical process. The first thing you should ask the

patient in the interview is the reason for their visit. The symptoms the patient is experiencing and

the patient's chief complaint. If the patient is coming for a general visit ask the patient about

general health and lifestyle and about any changes in the health status since the last visit. The

history of the patient provides information for research, reportable diseases, and insurance

claims. Document all information regarding the patient precisely and accurately.

When communicating with the patient make sure you are using effective listening, being

aware of nonverbal clues and body language, using broad knowledge base, and summarizing to

form a general picture. As you are not the doctor make sure to avoid giving your opinion about

diagnosis. General purpose of getting a patient's medical history is to include their age, previous

illness, surgical history, allergies, medication history, and family medical history.
 Vital Signs and Measurements

Vital signs are very important to the assessment and treatment of the patient. Vitals sings

are include temperature, pulse, respirations, blood pressure, and pain assessment. Changes in the

vital signs can indicate an abnormality. Measurements like height, weight, and head

circumference can help indicate physical growth and development but can also be used to help

evaluate health problems. Vital signs are usually measured at every office visit and each patient

has an individual baseline value that is normal for them. When checking a patient's temperature

the normal oral value is 98.6 Fahrenheit and 37.0 Celsius. The average pulse is between 60 to

100 beats per minute, pulse must be taken for a whole minute. Respiration can indicate how well

a patient's body is providing oxygen to tissues. When listening to a patient listen for the sounds

of each breath and periods of apnea. The average amount of breaths in a minute is 12-20. Blood

pressure is the force at which blood is pumped against the wall of the arteries. Hypertension is

high blood pressure that is a common health among people that can become a serious issue and

should be watched closely. Normal blood pressure has a systolic reading below 120 and diastolic

reading less than 80. When measuring a patients weight, it should be recorded the nearest

quarter of a pound. Height should be taken at least once a year and should be measured to the

nearest quarter of an inch. If a patient a patient has wound, bruise, or other injury should measure

its length and width to evaluate the healing process.

The physical exam is the first step in the process for the physician or other license

practitioner. As a medical assistant you should make the patient comfortable and help the

physician as much as possible. If the medical assistant makes the patient feel good and create a

positive atmosphere or the patient the results will be more accurate. The purpose of a physical

exam is to examine a patients overall health and to provide baseline values for vital signs and

measurements. The job of the medical assistant during the exam is to ensure all instruments and

supplies are available for the practitioner. Make sure to observe the patient for discomfort or

distress. The patient should be explained exactly what to except during the exam and how they

are excepted to contribute to the exam. There are multiple ways to examine a patient this can

include inspection which is visual exam of the patients entire body and over-all appearance.

Auscultation the process of listening to body sounds, palpation which is touching the patient to

feel texture and shape, percussion which is tapping the body to hear sounds, mensuration the

process of measuring, and manipulation the moving of a patients body part are all examination

methods.

When a physical exam is being perform the following areas should be examined in this

order; head, neck, eyes, ears, nose and sinuses, mouth and throat, chest and lungs, heart , breast,

abdomen, genitalia, rectum, musculoskeletal system, neurological system. Before the exam starts

all supplies should be stocked and ready in the examination room this can include penlight,

otoscope, vision chart, color vision, audiometer, nasal speculum, gloves, tongue depressor,

stethoscope, vaginal speculum, lubricant, and tape measure. The medical assistant is responsible

for the follow-up care needed for the patient based on physicians recommendations.
 Assisting in Reproductive and Urinary Specialties

Obstetrics involves the study of pregnancy, labor, delivery, and postpartum care. An

urologist diagnoses and treats disorders and diseases of both female and male urinary systems as

well as the male reproductive system. The most important job of the medical assistant is to assist

the person doing the examination and provide patient education. When working in an office you

should know the signs of labor and when to tell patients to go to the hospital. The medial

assistant should be prepared and know the steps of emergency childbirth. Also you should show

support for breastfeeding mothers by giving them pamphlets and directing them to lactation

consultants.

There are many diagnostic tests that are performed at offices that a medical assistant may

need to perform or explain to patients. These tests could include pregnancy test, tests for sexually

transmitted infections, radiologic tests, and fetal screening. There are important radiologic test

such as hysterosalpingography which is an x-ray exam of the fallopian or uterine tubes and

mammogram which is a picture of the breasts on film or digital media. Urologists have their own

set of procedures and test that are performed. These tests and include urine and blood test, semen

analysis and smears, cystometry, cystoscopy, and testicular biopsy.

Sexually transmitted infections that are diseases acquired through sexual contact with an

infected person are a common thing among patients. As a medical assistant the role of an

educator is very important in dealing with people who have STIs. Make sure you are open and

willing to help answer a question one might have about the diseases.
 Assisting In Pediatrics

Pediatrics is the area of medicine that involves the care of children. The responsibility of

the medical assistant is to include parent or caregiver education, adherence to immunization

schedules, and recognition of special health concerns. Many exam procedures are the same for

children as adults. You can help relieve a childs fear by calmly explaining procedures before

they occur and having a cheerful and mindful of childs feelings. Avoid making light or crying or

pain. Make a game out of some aspect of a procedure and provide small tokens of rewards at the

end of a visit.

Immunizations are an important factor in the care of pediatrics. They reduce the

susceptibility of the host to infection. Immunizations are usually given during regular check-ups

these can include immunizations such as hepatitis B, diphtheria, tetanus, pertussis, poliomyelitis,

measles, mumps, rubella, and chickenpox. As medical assistant you could be administering the

vaccine and keeping careful immunization records. It is important to explain the benefits and

risks of immunization to the parents.

A medical assistant is a vital part of the healthcare team. They can help a facility run

smoothly and properly. Patients look toward the medical assistants for guidance and information

and the medical assistant needs to be prepared to help educate the patients. The medical assistant

is the first person the patient sees as they enter and leave the office so the attitude and

organization and create a lasting impact on the patient of the facility and its care.