, Contents
1 Introduction to Medical Assisting 1
2 Healthcare and the Healthcare Team 11
3 Professionalism and Success 17
4 Interpersonal Communication 25
5 Legal and Ethical Issues 39
6 Infection Control Fundamentals 53
7 Safety and Patient Reception 67
8 Office Equipment and Supplies 85
9 Examination and Treatment Areas 101
10 Written and Electronic Communication 113
11 Medical Records and Documentation 133
12 Electronic Health Records 149
13 Managing Medical Records 163
14 Telephone Techniques 177
15 Patient Education 197
16 Schedule Management 213
17 Insurance and Billing 237
18 Diagnostic Coding 257
19 Procedural Coding 275
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20 Patient Collections and Financial Management 295
21 Organization of the Body 333
22 The Integumentary System 343
23 The Skeletal System 351
24 The Muscular System 361
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25 The Cardiovascular System 369
26 The Blood 379
27 The Lymphatic and Immune Systems 387
28 The Respiratory System 395
29 The Nervous System 403
30 The Urinary System 411
31 The Reproductive Systems 419
32 The Digestive System 429
33 The Endocrine System 439
v
,34 Special Senses 447
35 Infection Control Practices 457
36 Patient Interview and History 473
37 Vital Signs and Measurements 485
38 Assisting with a General Physical Examination 505
39 Assisting in Reproductive and Urinary Specialties 527
40 Assisting in Pediatrics 539
41 Assisting in Geriatrics 551
42 Assisting in Other Medical Specialties 561
43 Assisting with Eye and Ear Care 575
44 Assisting with Minor Surgery 599
45 Orientation to the Lab 625
46 Microbiology and Disease 635
47 Collecting, Processing, and Testing Urine and Stool Specimens 655
48 Collecting, Processing, and Testing Blood Specimens 679
49 Electrocardiography and Pulmonary Function Testing 701
50 Diagnostic Imaging 719
51 Principles of Pharmacology 731
52 Dosage Calculations 745
53 Medication Administration 755
54 Physical Therapy and Rehabilitation 787
55 Nutrition and Health 805
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56 Practice Management 817
57 Emergency Preparedness 835
58 Preparing for the World of Work 859
WORK DOCUMENTATION: ADMINISTRATIVE 865
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WORK DOCUMENTATION: CLINICAL 937
vi Contents
, Procedures
INSTRUCTIONS FOR THE PROCEDURE CHECKLISTS
General Instructions
Review and practice the correct performance of each procedure prior to attempting the procedure. The rationales for all
critical steps are given in the performance guidelines within your textbook. Review these steps and rationales carefully
before beginning the procedure. As you become more proficient in the procedure, you should perform the procedure
without guidance from the textbook or the reviewer. In any procedure, certain steps are considered to be more important
than others. These steps are referred to as critical steps. If any of these steps are missed or performed incorrectly,
you should continue to practice the procedure to perfect the technique. Steps with an * are considered critical steps.
Scoring System
The scoring system is based on 100 points so that they are easily converted to 100 percent. Each step has been given a
point value based on its importance to completing the procedure. Note that steps with an * are considered critical steps. If
a critical step is not done correctly, you may be considered unsuccessful in completing the procedure during that attempt.
PROCEDURES LIST
Procedure 1-1 Obtaining Certification/Registration Information Through the Internet 7
Procedure 1-2 Locate Your State’s Legal Scope of Practice 9
Procedure 3-1 Self-Evaluation of Professional Behaviors 23
Procedure 4-1 Communicating with the Anxious Patient 33
Procedure 4-2 Communicating with the Angry Patient 35
Procedure 4-3 Communicating with the Assistance of an Interpreter 37
Procedure 5-1 Obtaining Signature for Notice of
Privacy Practices and Acknowledgment 47
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Procedure 5-2 Completing a Privacy Violation Complaint Form 49
Procedure 5-3 Obtaining Authorization to Release Health
Information 51
Procedure 6-1 Aseptic Handwashing 59
Procedure 6-2 Using an Alcohol-Based Hand Disinfectant 61
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Procedure 6-3 Using a Biohazardous Sharps Container 63
Procedure 6-4 Disposing of Biohazardous Waste 65
Procedure 7-1 Handling a Fire Emergency 75
Procedure 7-2 Maintaining and Using an Eyewash Station 77
Procedure 7-3 Creating a Pediatric Reception Area 79
Procedure 7-4 Creating a Reception Area Accessible to Patients
with Special Needs 81
Procedure 7-5 Opening and Closing the Medical Office 83
Procedure 8-1 Using a Facsimile (Fax) Machine 93
Procedure 8-2 Using a Photocopier Machine 95
vii
,Procedure 8-3 Using a Check-Writing Machine 97
Procedure 8-4 Step-by-Step Overview of Inventory Procedures 99
Procedure 9-1 Performing Sanitization with an Ultrasonic Cleaner 109
Procedure 9-2 Guidelines for Disinfecting Exam Room Surfaces 111
Procedure 10-1 Creating a Professional Letter 123
Procedure 10-2 Writing an Interoffice Memo 125
Procedure 10-3 Composing a Professional E-mail Message 127
Procedure 10-4 Composing an Electronic Patient Letter Using a Template 129
Procedure 10-5 Sorting and Opening Mail 131
Procedure 11-1 Preparing a New Patient Paper Medical Record 143
Procedure 11-2 Correcting Paper Medical Records 145
Procedure 11-3 Entering (Adding) Information into a Paper Medical Record 147
Procedure 12-1 Creating a New Patient Record Using EHR Software 155
Procedure 12-2 Checking in and Rooming a Patient Using an Electronic
Health Record 157
Procedure 12-3 Creating an Appointment Matrix for an Electronic Scheduling System 159
Procedure 12-4 Scheduling a Patient Appointment Using an Electronic Scheduler 161
Procedure 13-1 Creating a Filing System for Paper Medical Records 171
Procedure 13-2 Setting Up an Office Tickler File 173
Procedure 13-3 Developing a Records Retention Program 175
Procedure 14-1 Using a Video Relay Service with an American Sign
Language Interpreter 185
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Procedure 14-2 Renewing a Prescription by Telephone 187
Procedure 14-3 Screening and Routing Telephone Calls 189
Procedure 14-4 Handling Emergency Calls 191
Procedure 14-5 Retrieving Messages from an Answering Service
or System 193
Procedure 14-6 Participating in a Telehealth
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Interaction with a Patient 195
Procedure 15-1 Creating Electronic Patient Instructions 203
Procedure 15-2 Identifying and Using Community Resources 205
Procedure 15-3 Locating Credible Patient Education Information on the Internet 207
Procedure 15-4 Developing a Patient Education Plan 209
Procedure 15-5 Outpatient Surgery Teaching 211
Procedure 16-1 Creating an Appointment Matrix 225
Procedure 16-2 Scheduling Appointments 227
Procedure 16-3 Completing the Patient Appointment Card 229
viii Procedures
, Procedure 16-4 Placing Appointment Confirmation Calls 231
Procedure 16-5 Scheduling Outpatient Surgical Appointments 233
Procedure 16-6 Scheduling Inpatient Surgical Appointments 235
Procedure 17-1 Verifying Workers’ Compensation Coverage 247
Procedure 17-2 Submitting a Request for Prior Authorization 249
Procedure 17-3 Completing the CMS-1500 Claim Form 251
Procedure 17-4 Tracking Insurance Claims Submissions 255
Procedure 18-1 Locating an ICD-10-CM Code 269
Procedure 18-2 Locating a Health Status (Z) Code 271
Procedure 18-3 Locating an External Cause Code 273
Procedure 19-1 Locating a CPT Code 289
Procedure 19-2 Locating an HCPCS Code 291
Procedure 19-3 Entering CPT and ICD Codes into an EHR Program 293
Procedure 20-1 Posting Charges, Payments, and Adjustments 311
Procedure 20-2 Using the Superbill as Bill/Receipt 313
Procedure 20-3 Posting a Nonsufficient Funds (NSF) Check 315
Procedure 20-4 Processing a Payment Resulting in a Credit Balance 317
Procedure 20-5 Processing Refunds to Patients 319
Procedure 20-6 Preparing an Age Analysis 321
Procedure 20-7 Referring an Account to a Collection Agency and Posting
the Payment from the Agency 323
Procedure 20-8 Completing a Truth in Lending Statement
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(Agreement) 325
Procedure 20-9 Making a Bank Deposit 327
Procedure 20-10 Reconciling the Bank Statement 329
Procedure 20-11 Setting Up the Disbursements Journal 331
Procedure 35-1 Removing Contaminated Gloves 463
Procedure 35-2 Removing a Contaminated Gown 465
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Procedure 35-3 Wrapping and Labeling Instruments for Sterilization in the Autoclave 467
Procedure 35-4 Running a Load Through the Autoclave 469
Procedure 35-5 Notifying State and County Agencies About
Reportable Diseases 471
Procedure 36-1 Using Critical Thinking Skills During an Interview 479
Procedure 36-2 Using a Progress Note 481
Procedure 36-3 Obtaining a Medical History 483
Procedure 37-1 Measuring and Recording Temperature 495
Procedure 37-2 Measuring and Recording Pulse and Respirations 497
Procedures ix
,Procedure 37-3 Obtaining a Pulse Oximetry Reading 499
Procedure 37-4 Taking the Blood Pressure of Adults and
Older Children 501
Procedure 37-5 Measuring Height and Weight of
Adults and Children 503
Procedure 38-1 Practicing Good Body Mechanics 517
Procedure 38-2 Positioning a Patient for an Exam 519
Procedure 38-3 Communicating Effectively with Patients from Other
Cultures and Meeting Their Needs for Privacy 521
Procedure 38-4 Transferring a Patient in a Wheelchair for an Exam 523
Procedure 38-5 Assisting with a General Physical Exam 525
Procedure 39-1 Assisting with a Gynecologic Exam 533
Procedure 39-2 Assisting During the Exam of a Pregnant Patient 535
Procedure 39-3 Assisting with a Cervical Biopsy 537
Procedure 40-1 Measuring Infants 545
Procedure 40-2 Maintaining Growth Charts 547
Procedure 40-3 Collecting a Urine Specimen from a Pediatric
Patient 549
Procedure 41-1 Coaching and Communicating with Geriatric Patients 557
Procedure 41-2 Educating Adult Patients About Daily Water
Requirements 559
Procedure 42-1 Assisting with a Scratch Test Examination 569
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Procedure 42-2 Assisting with a Sigmoidoscopy 571
Procedure 42-3 Assisting with a Needle Biopsy 573
Procedure 43-1 Preparing the Ophthalmoscope for Use 583
Procedure 43-2 Performing Vision Screening Tests 585
Procedure 43-3 Administering Eye Medications 589
Procedure 43-4 Performing Eye Irrigation 591
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Procedure 43-5 Measuring Auditory Acuity 593
Procedure 43-6 Administering Eardrops 595
Procedure 43-7 Performing Ear Irrigation 597
Procedure 44-1 Creating a Sterile Field 611
Procedure 44-2 Performing a Surgical Scrub 613
Procedure 44-3 Donning Sterile Gloves 615
Procedure 44-4 Assisting as a Floater (Unsterile Assistant)
During Minor Surgical Procedures 617
Procedure 44-5 Assisting as a Sterile Scrub Assistant During Minor
Surgical Procedures 619
x Procedures
, Procedure 44-6 Assisting After Minor Surgical Procedures 621
Procedure 44-7 Suture Removal 623
Procedure 45-1 Using a Microscope 633
Procedure 46-1 Obtaining a Throat Culture Specimen 643
Procedure 46-2 Performing a Quick Strep A Test on a Throat
Specimen 645
Procedure 46-3 Obtaining a Nasopharyngeal Culture Specimen 647
Procedure 46-4 Preparing Microbiologic Specimens for Transport
to an Outside Laboratory 649
Procedure 46-5 Preparing a Microbiologic Specimen Smear 651
Procedure 46-6 Performing a Gram Stain 653
Procedure 47-1 Collecting a Clean-Catch Midstream Urine Specimen 663
Procedure 47-2 Collecting a 24-Hour Urine Specimen 665
Procedure 47-3 Establishing Chain of Custody for a Urine
Specimen 667
Procedure 47-4 Measuring Specific Gravity with a Refractometer 669
Procedure 47-5 Performing a Reagent Strip Test 671
Procedure 47-6 Pregnancy Testing Using the EIA Method 673
Procedure 47-7 Processing a Urine Specimen for Microscopic
Examination of Sediment 675
Procedure 47-8 Fecal Occult Blood Testing Using the Guaiac
Testing Method 677
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Procedure 48-1 Quality Control Procedures for Blood Specimen
Collection 687
Procedure 48-2 Performing Venipuncture Using an Evacuated
System 689
Procedure 48-3 Performing Capillary Puncture 691
Procedure 48-4 Preparing a Blood Smear Slide 693
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Procedure 48-5 Measuring Hematocrit Percentage After Centrifuge 695
Procedure 48-6 Measuring Blood Glucose Using a Handheld
Glucometer 697
Procedure 48-7 Performing a Rapid Infectious Mononucleosis Test 699
Procedure 49-1 Obtaining an ECG 711
Procedure 49-2 Ambulatory Monitoring 713
Procedure 49-3 Measuring Forced Vital Capacity Using Spirometry 715
Procedure 49-4 Obtaining a Peak Expiratory Flow Rate 717
Procedure 50-1 Assisting with an X-ray Examination 727
Procedure 50-2 Documentation and Filing Techniques for X-rays 729
Procedures xi
,Procedure 51-1 Helping the Licensed Practitioner Comply with the
Controlled Substances Act 741
Procedure 51-2 Interpreting a Prescription 743
Procedure 53-1 Administering Oral Drugs 763
Procedure 53-2 Administering Buccal or Sublingual Drugs 765
Procedure 53-3 Drawing a Drug from an Ampule 767
Procedure 53-4 Reconstituting and Drawing a Drug for Injection 769
Procedure 53-5 Giving an Intradermal (ID) Injection 771
Procedure 53-6 Giving a Subcutaneous (Subcut) Injection 773
Procedure 53-7 Giving an Intramuscular (IM) Injection 775
Procedure 53-8 Administering Inhalation Therapy 777
Procedure 53-9 Administering and Removing a Transdermal Patch 779
Procedure 53-10 Assisting with Administration of a Urethral Drug 781
Procedure 53-11 Administering a Vaginal Medication 783
Procedure 53-12 Administering a Rectal Medication 785
Procedure 54-1 Administering Cryotherapy 793
Procedure 54-2 Administering Thermotherapy 795
Procedure 54-3 Teaching a Patient How to Use a Cane 799
Procedure 54-4 Teaching a Patient How to Use a Walker 801
Procedure 54-5 Teaching a Patient How to Use Crutches 803
Procedure 55-1 Teaching Patients How to Read Food Labels 813
Procedure 55-2 Alerting Patients with Food Allergies to the
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Dangers of Common Foods 815
Procedure 56-1 Preparing a Travel Expense Report 827
Procedure 56-2 Preparing an Agenda 829
Procedure 56-3 Completing an Incident Report 831
Procedure 56-4 Generating Payroll 833
Procedure 57-1 Stocking the Crash Cart 843
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Procedure 57-2 Performing an Emergency Assessment 845
Procedure 57-3 Foreign Body Airway Obstruction in a Responsive Adult or Child 847
Procedure 57-4 Foreign Body Airway Obstruction in a Responsive Infant 849
Procedure 57-5 Controlling Bleeding 851
Procedure 57-6 Cleaning Minor Wounds 853
Procedure 57-7 Caring for a Patient Who Is Vomiting 855
Procedure 57-8 Assisting During a Chemical Disaster 857
Procedure 58-1 Résumé Writing 863
xii Procedures
, 1
Introduction to Medical Assisting
Name Class Date
R E V I E W
Vocabulary Review
Matching
Match the key terms in the right column with the definitions in the left column by placing the letter of each correct answer in
the space provided.
1. Education or training received after a medical assistant is credentialed a. ABHES
b. accreditation
2. The only professional association devoted exclusively to the medical
c. AAMA
assisting profession
d. AMT
3. Official authorization or approval of schools or programs that teach e. certification
medical assisting f. CAAHEP
g. CMA
4. The granting of a title or license by a board that gives permission to
h. continuing education
practice in a profession
i. cross-training
5. Provides separate administrative and clinical certifications only j. NHA
k. professional development
6. The credential earned by taking an AAMA-approved course and
l. RMA
passing the licensing exam
m. registration
7. Skills and knowledge attained for both personal development and n. licensed practitioner
career advancement o. résumé
No reproduction or distribution without the prior written consent of McGraw Hill LLC.
8. An organization that accredits both public and private postsecondary
institutions that offer medical assisting programs
9. The credential earned by taking an AMT-approved course and passing
the licensing exam
10. A computer-generated document that summarizes your employment
and educational history
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11. An organization that accredits private postsecondary institutions that
offer medical assisting programs
12. A professional organization for medical assistants and other allied
healthcare personnel
13. Confirmation by an organization that an individual is qualified to
perform a job to professional standards
14. Training for other jobs in your department or in other departments,
in addition to medical assisting
15. An individual other than a physician who is licensed or otherwise
authorized by the state to provide healthcare services
Chapter 1: Introduction to Medical Assisting 1