MAP 347 - Medical Office Procedures I

1. Assess a patient’s vital signs
   1. Explain the physiology pertaining to temperature, pulse, respiration, blood pressure and pulse oximetry
   2. State adult and pediatric normal ranges for each vital sign
   3. List variables affecting each of the vital signs
   4. Describe characteristics for each vital sign
   5. Locate arteries on the body where pulse rate can be obtained
   6. Explain factors that determine arterial blood pressure
   7. Identify organs affected by hypertension
   8. Perform proper technique for measurement of each vital sign
   9. Describe methods for care of equipment used in measuring vital signs
   10. Obtain and record temperature, pulse, respiration, blood pressure and pulse oximetry
   11. Recognize and report age specific normal and abnormal vital signs
2. Use appropriate mensuration techniques
   1. Weigh a patient on a balance scale and a digital scale, adult and pediatric
   2. Measure circumference of the chest on inspiration and exhalation
   3. Measure the circumference of the head and chest of an infant
   4. Measure patient height and infant length
   5. Correctly document measurements on patient chart and growth chart
   6. Define and perform BMI
   7. Compute and analyze BMI from patient measurements
   8. Prepare and analyze growth charts
3. Complete a patient history for patient intake
   1. Differentiate between subjective and objective information
   2. State three reasons for obtaining a medical history
   3. Define the six components of a patient history
   4. Relate the importance of maintaining an ongoing record of physical problems for each patient
   5. Correlate the importance of correct documentation and confidentiality of the patient medical record
   6. Prepare patient chief complaint, history of present illness, past history, family history, and social and occupational history
   7. Perform a review of the body systems
   8. Adapt communications to patient ability to understand
   9. Use effective and correct verbal and written communications
   10. Recognize and respond to verbal and non-verbal communications
   11. Use medical terminology correctly and pronounced accurately to communicate information to providers and patients
   12. Coach patients appropriately considering: cultural diversity,developmental life stage and communication barriers
   13. Report relevant information to others concisely and accurately
   14. Use feedback techniques to obtain patient information including: reflection; restatement and clarification
   15. Demonstrate use of components of documentation: factual, timely, legible, dated, signed
4. Prepare a medical record
   1. List components included in the source oriented medical record (SOMR)
   2. Identify the components of the Problem Oriented Medical Record (POMR).
   3. State three advantages of the Problem Oriented Medical Record
   4. Compare and contrast the differences between the Problem Oriented Medical Record and the traditional medical record
   5. Demonstrate how to change an entry in the medical record
   6. Differentiate purpose and advantages of advanced directives; living will, power of attorney and treatment preferences
   7. Describe where patients obtain necessary forms for advance directives. State who needs to witness these forms, and where should they be stored
   8. Discuss the stages of grief, death and dying
   9. Document accurately in patient record
   10. Document patient care, patient response and patient education
   11. Incorporate HIPAA, NPP, meaningful use, consent and Patient Self Determination Act in patient record.
5. Prepare a patient for a physical examination
   1. List the purposes for the general physical examination
   2. Classify six categories of diagnoses used by the physician
   3. Describe six major methods of examination used by the physician
   4. Describe the role of diagnostic testing as a component of the physical examination process
   5. Summarize the purposes for positioning, gowning, and draping a patient for a physical exam
   6. Identify procedures associated with specialty exams
6. Assist with a physical examination
   1. Determine the equipment used in the physical examination
   2. Demonstrate positions used during a physical examination
   3. Describe the sequence of a comprehensive physical examination
   4. Discuss the role of the Medical Assistant when assisting with the physical examination
   5. Demonstrate care of equipment used during the physical examination
   6. Discuss and give examples of guidelines to use in preparing and providing patient education in areas of treatment, preventative care, health and wellness
   7. Demonstrate effective patient teaching skills
   8. Identify community resources for health care information and patient referrals
   9. Explain the rationale for performance of a procedure to the patient
   10. Show awareness of patient concerns regarding their perceptions related to the clinical procedure being performed
   11. Analyze healthcare results reported in  a.) graphs and b.) tables
   12. Instruct and prepare a patient for a procedure or treatment
7. Explain methods of infection control
   1. Identify five classifications of microorganisms capable of causing disease
   2. List six factors essential for the development of an infectious process
   3. Compare direct/indirect modes of transmission of an infectious disease
   4. Describe the body’s natural defense mechanisms to control or prevent infection
   5. Define the following as practiced within an ambulatory care setting: medical asepsis; surgical asepsis
   6. Describe procedures used to accomplish medical/surgical asepsis
   7. Differentiate between sanitization, disinfection, and sterilization
   8. Discuss the procedures employed when working with contaminated equipment and supplies
   9. Explain the role of hand washing in the prevention of the spread of infectious disease. Distinguish hand hygiene with handwashing and alcohol based hand rub
   10. Identify methods of controlling the growth of micro organisms
   11. Demonstrate the proper procedures for hand washing using soap and water and alcohol based hand rub
8. Prepare items for sterilization
   1. Describe five methods of sterilization
   2. Explain the importance of sanitization prior to sterilization
   3. Explain why instruments and supplies are sterilized before use in a specific procedure
   4. Describe materials appropriate for wrapping materials for sterilization in the autoclave
   5. Demonstrate packaging procedures for instruments and supplies prior to sterilization
9. Perform sterilization procedures
   1. Describe the process of sterilization using the autoclave
   2. Describe the structure of the autoclave
   3. List the components of the sterilization cycle to assure items are sterile
   4. Demonstrate proper use of sterilization indicators
   5. Demonstrate proper technique for loading the autoclave, completing a cycle, unloading/storing sterile materials
   6. Describe process of using chemical sterilant
   7. Transfer sterile items from chemical sterilant to sterile field
   8. Explain the importance of quality control measures to be used with sterilization of instruments and supplies
   9. Perform autoclave QC testing with biological indicators and proper documentation of results
10. Assist with surgical procedures
    1. Identify and state purpose of the following instruments and equipment used in a surgical procedure: forceps; hemostats; needle holder; suture scissors; tissue scissors; probe; retractor; towel clamp; scalpel and suture
    2. Describe the use of cryotherapy, electrosurgery, laser surgery and cautery in the clinical office
    3. List pre-operative and post-operative issues to be addressed with the patient and care giver to include the use of consent forms and patient education procedures
    4. Obtain informed consent forms
11. Set up a surgical tray using correct aseptic techniques for various sterile procedures preformed in an office
    1. Differentiate between medical and surgical asepsis used in ambulatory care settings, identifying when each is appropriate
    2. Demonstrate a medical aseptic hand washing and the surgical scrub
    3. Demonstrate the use of sterile transfer forceps to maintain a sterile field
    4. Demonstrate the process for setting up a tray using a pre-packaged set of surgical instruments, and by using the transfer forceps and multiple use containers
    5. Demonstrate the technique for opening sterile packages
    6. Demonstrate the technique for pouring sterile solutions
    7. List the instruments and supplies needed for various surgical procedures performed in the office
    8. Explain the purpose of correct placement of instruments on the surgical tray
12. Assist the physician with surgical or other sterile procedures
    1. Demonstrate the techniques and principles of hand washing, sterile gloving, and handling sterile supplies
    2. Describe the Medical Assistant role in assisting with a surgical procedure
    3. Demonstrate donning and removing sterile gloves
    4. Demonstrate the position of instruments in handing to the physician
    5. Demonstrate the ability to use proper techniques in a simulated surgical procedure
    6. Describe various types of anesthesia used in the medical office
13. Instruct patients on physical therapy
    1. Describe the use of moist and dry applications of heat and cold
    2. List the effects that occur from local application of heat and cold
    3. List contraindications for application of heat or cold
    4. Describe the general use of ultrasound
    5. Describe the general use of diathermy
    6. List the guidelines for safe crutch use
    7. Identify conditions that would warrant use of a cane and/or walker
    8. Explain to patients how to care for and use special equipment
    9. Provide written and verbal instructions for patient education
    10. Demonstrate proper use of assisting patient with wheel chair, walker, single cane,quad cane, crutches and gait belt
14. Assist with specialty exams and procedures
    1. Identify materials and equipment needed for female pelvic exam and Pap smear,both traditional and liquid pap, and wet mount
    2. Explain purpose and procedure to assist with a sigmoidoscopy
    3. Demonstrate how to instill ear and eye drops
    4. Demonstrate how to irrigate the eye and ear
    5. Set up and perform pulmonary function testing,spirometry and peak flow rate
    6. Explain purpose and procedure for urinary catheterization in male,female and pediatric patients for urine collection
    7. Demonstrate proper use of emergency oxygen equipment
    8. State the purpose and procedure for special testing and screening as in PKU, lead poisoning,occult blood, PSA and FAS
    9. Perform and document calibration of PFT
15. Assist patients with special needs
    1. Describe ways to help children cope with the fear of medical procedures
    2. Discuss appropriate ways of interaction and dealing with patients with special needs
    3. Discuss appropriate ways of interaction and dealing with elderly patients, patients with physical, mental and emotional disabilities
    4. Instruct patient according to their needs to promote health maintenance and disease prevention
    5. Describe methods of coordinating care and optimizing rehabilitation for patient with chronic disease or condition
    6. Discuss how the medical assistant can serve as a patient advocate for the patient with chronic pain, chronic and terminal illness
    7. Identify tools to enhance patient education
    8. Discuss techniques in patient education that will encourage patient compliance
    9. Name symptoms and conditions associated with alcohol and drug abuse
    10. Identify alcohol and drug abuse treatment and prevention methods
    11. Discuss the impact of stress on health and wellness
    12. Identify mechanisms for coping with stress and stress reduction
16. Develop patient education material
    1. Discuss techniques in patient education that will encourage patient compliance
    2. Identify examples of patient education to include treatment, prevention,compliance and health and wellness
    3. Instruct patients according to their needs and abilities
    4. Identify techniques for overcoming communication barriers
    5. Define coaching a patient as it relates to health maintenance; disease prevention, compliance with treatment plan, community resources and adaptations relevant to individual patient needs
17. Utilize critical thinking skills
    1. Formulate questions to determine if important information is lacking
    2. Reject information that is not accurate, relevant, precise or clear
    3. Double check all facts
    4. Examine the situation and evaluate the problem without bias or judgment
    5. Assess the situation for reason and logic
    6. Determine and state the goal to be accomplished
    7. Follow steps for implementation/problem solving
    8. Evaluate outcomes
    9. Incorporate critical thinking skills when performing patient assessment
    10. Incorporate critical thinking skills when performing patient care