Clinical Medical Assistant Certification AMCA Study Guide

Clinical Medical Assistant Certification AMCA Study Guide Communication Methods Ans- • Listening • Face the person • Have good eye contact • Lean toward the person • Respond to the person • Paraphrasing- in your own words (shows you're really listening) • Clarifying • Silence- don't always have to say something Nonverbal Communication Ans- 1.) Kinesics- study of nonverbal communication a.) kinesic slip- where verbal and nonverbal messages do not match Zones of Comfort Ans- • Intimate space (18 in or closer • Personal space (18 in. to 4ft) • Social space (4ft to 12ft) • Public space (12ft or more) Phone Etiquette Ans- • When speaking on the phone always identify yourself to the caller. • Give your undivided attention and willingness to help. • Listen w/o interrupting, provide reasonable alternatives and take a clear concise message in order for the call to be returned. Answering the Phone Ans- • Answer promptly and kindly. • NEVER ALLOW AND ANGRY OR AGGRESSIVE CALLER TO UPSETYOU; RMAIN CALM AND COMPOSED. • Speak clearly and concisely • Be sure to ask the callers permission before placing them on hold E-mail is a quick and easy way to communicate Ans- • Use a personal name if your system allows it • Fill in the subject line to identify your message • DO NOT write a message with upper case as this may be perceived as expressing anger • ALWAYS CHECK WHO THE RECIEVER OF THE MAIL IS BEFORE YOU CLICK SEND • Use "please" and " thank you" • REMEMBER, email could be used as a legal document, NEVER threaten or intimidate someone; even in jest. Forms of Charting Ans- • Narrative - written description of patients visits in chronological order • SOAP Note Charting - Method that tracks subjective, objective, assessment and plan for a patients visit. 1. Subjective - Patients statements (Chief Complaint) 2. Objective - Observations made by the medical assistant, examination findings and vital a.) Signs 3. Assessment - Doctors diagnosis 4. Plan - Health care providers prescribed plan of action • POMR Problem-Oriented Medical Record Charting - Tracks a patient's problems throughout medical care. a.) Each problem is assigned a # and the # is referenced when the patient comes in. • Flow Charts- Visual tools that help track certain information in patient's medical records like an infant's/ child's growth • Progress Notes - daily chart notes made during patient's visits to document patient progress with certain conditions Medical Records Ans- • Are a written account of a patient's condition and response to treatment and care • There are many parts to it: Admission sheet Nursing history Graphic sheet Progress notes Flow sheets Reporting is the oral account of care and Recording is the written account of care and observations Assessment involves collecting information about the person and observation is using the sense of sight, hearing, touch and smell to collect information. Objective Data: is information that is heard, felt or smelled. Subjective data are things a person's tells you about that you cannot observed through your senses. Word Elements Ans- • Prefix - comes before the root word • Root word - relating to specific body parts • Suffix - comes after the root word • Combing vowel - makes the word easier to say Body Direction Terms Ans- • Ventral - front part of body • Dorsal - back part of body • Anterior - in front of • Posterior - toward the back part of body • Medical - towards the midline of the body • Lateral - towards the side of the body • Proximal - closest to the point of origin • Distal - away from the point of origin • Frontal plane - divides the body into front and back portions • Transverse plane - divides the body into upper and lower portions Body Positions Ans- • Normal Anatomic Position - standing with arms lank and palms forward • Supine position - lying on back • Prone position - lying on stomach • Lateral recumbent position - lying on the side fowlers position Ans- Is the position of a patient who is lying in bed in a supine position with the head of the bed at approximately 30 to 45 degrees. Upright at 90 degrees is full or high Fowler's position Prone position Ans- Used to examine the spine and the back. patient lies on abdomen with head turned to one side for comfort. Arms may be above head or alongside body. Sims position Ans- A position in which the patient lies on one side with the under arm behind the back and the upper thigh flexed, used to facilitate rectal and vaginal examinations, also for enemas and treatments. Also called lateral recumbent position. This position is a variation of lateral position with the patient on the left side, left leg extended and right leg flexed. Trendelenburg position Ans- When a patient is placed in this position, he or she is lying face up, and the table on which the patient lies is angled do that the feet are above the head. in the reverse position, the patients orientation is switched so that the head lies above the feet. Dorsal recumbent position Ans- Is when the patient is on his/hoer back with knees flexed and soles of the feet flat on the bed. Patient care Ans- Pain is unpleasant and an emotional experience. Everyone responds differently to pain depending on their threshold. • Pain can be categorized as acute or chronic: a.) Acute pain, such as surgical pain usually lessens with treatment b.) Chronic pain, like that associated with arthritis, lasts longer possible for a lifetime 3 types of pain Ans- • Physical pain- this could be considered like chest pain or a severe stomach ache. I. This is usually a sign that something is wrong. • Psychological pain- like terror, fear, or grief II. This type of pain could lead to disorders such as depression, PTSD, or an anxiety disorder. • Phantom pain- this is pain that occurs after an amputation Making a pain assessment Ans- Questions to ask when making a pain assessment • When did the pain start? • Where is the pain? • How often do you feel the pain? • Does anything you do lesson the pain? • Describe the pain. Patient preparation and encounters Ans- As a medical assistant you may be responsible for various duties in the office including and etc.: • Triage of patients • Consent forms • Preparing third party information • Taking the patients signs • Updating medical charts Patient Preparation and Encounters Con.... Ans- • Implied Consent: Agreement implied by the patient for examination and treatment when presenting for a routine visit; also in an emergency consent that is assumed the patient would give if the patient could do so. • Informed Consent: Consent that is given buy the patient after all potential treatment and outcomes have been discussed for a specific medical condition, including risks and possible negative outcomes. • Triage: Sorting and setting priorities for treatment for patients who are on the phone or at the reception desk. • Sign: That which can be seen, heard, measured or felt by the examiner. • Symptom: A perceptible change in the body related by the patient. • Safety: An incident is an event that does not normally occur within the regular health care facility routine and may involve patients. Visitors, physicians, hospital staff or students. Requires written reports: 1. Accidents 2. Thefts from person on hospital property 3. Errors of omission of patient treatment or errors in administration of patient treatment, including medications 4. Exposure to blood and body fluids, as may be caused by a needle stick. Fire Ans- In the event of a fire, the HUC may be responsible to assist in the evacuation of the pts who are endangered by the fire. If the fire is elsewhere, the HUC is expected to assist the nursing personnel in closing the doors to the pts rooms. R Rescue individuals in danger A Sound the alarm C Confine the fire by closing all doors and windows E Extinguish the fire with the nearest suitable fire extinguisher. Electrical Safety Ans- A. Using Electrical Equipme