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Medical Assisting Exam Room

Medical Assisting Exam Room. Lisa H. Young, RN, BSN, MA Ed. Daymar College. Basic Safety & Infection Control. Maintain Safety Plan Infection Control & CDC Guidelines OSHA Guidelines Universal & Standard Precautions. Asepsis & Hand-washing.

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Medical Assisting Exam Room

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  1. Medical Assisting Exam Room Lisa H. Young, RN, BSN, MA Ed. Daymar College

  2. Basic Safety & Infection Control Maintain Safety Plan Infection Control & CDC Guidelines OSHA Guidelines Universal & Standard Precautions

  3. Asepsis & Hand-washing http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs

  4. Non-sterile Gloving

  5. Patient Interview and History How you conduct yourself during the first few moments with the patient can make a major difference in the patient’s attitude.

  6. Patient Interview and History http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs

  7. Health History Form • Personal data • Chief complaint (CC) • Reason patient made the appointment • Short and specific • History of present illness – detailed information about CC • Past medical history • All health problems • Medications • Allergies

  8. Health History Form http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs • Family history • May help determine cause of current problem • Ages, medical conditions • Age at death and cause • Social and occupational history • Marital status • Occupation • Sexual orientation • Alcohol/drug use • Review of systems – completed by practitioner

  9. Documentation Methods of Charting SOAP SOMR POMR Computerized (EHR) • Six Cs of Charting • Client’s own words • Clarity • Completeness • Conciseness • Chronological • Confidentiality

  10. Documentation The chart is a legal record of treatment provided. All information must be documented precisely and accurately! http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs • Date/time of entry • Legible handwriting • Permanent black ink • Proper terminology, correct spelling and correct grammar • Correct errors • Sign every entry

  11. Contents of the Patient Chart Registration form Patient medical history Test results Records from other physicians or hospitals Physician’s diagnosis and treatment plan Operative reports Informed consents Discharge summary Correspondence

  12. Vital Signs Heat pockets http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs Vital Signs: Temperature (T) (Oral / Aural / Axillary / Rectal) Normal Range for all Ages 96.4 – 99.1 F

  13. Vital Signs http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs • Pulse (P) • Radial • Adult:60 – 100 bpm • Children: (6 – 12):70 – 120 bpm (1 – 5): 80 – 150 bpm • Infant (<1): 100 – 160 bpm

  14. Vital Signs • Apical Pulse

  15. Vital Signs Electronic Measuring Device

  16. Vital Signs http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs • Respirations ( R ) • Depth • Rate • Regularity • Adult: 20 breaths per minute • Children (6-12): 18 – 30/min (1 – 5): 24 -34 /min • Infant (< 1): 30 – 60 /min

  17. Vital Signs • Blood Pressure (BP) • Systolic / Diastolic • Equipment: • Sphygmomanometer (cuff widths) • Stethoscope (Kortkoff sound) • Average blood pressure readings • Newborn: 80/50 mmHg • Infant: 90/60 mmHg • Child 3 – 6 yrs.: 100/60 mmHg • Child 10 yrs.: 110/60 mmHg • Child 14 yrs.: 130/60 mmHg • Adult: 120/80 mmHg • Elderly > 60 yrs. : 155/95 mmHg

  18. Vital Signs

  19. Blood Pressure Hypertension Hypotension http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs

  20. Vital Signs • Pain Assessment Interviewing technique – PQRST • Provoke or palliative • Quality or Quantity • Region or Radiation • Severity scale • Timing

  21. Height and Weight Measurement Mensuration Pounds/ Kilograms BSA Nomogram http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs

  22. Body Measurement Body Mass Index (BMI)

  23. Assisting with Physical Exam • Outline sequence of physical exam Skin Mouth Genitalia Hair Throat Rectum Nails Arms Legs Head Heart Feet Neck Chest Neurological Eyes Lungs Ears Breasts Nose Abdomen

  24. Assisting with Physical Exam http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs • Communicating with patients from other cultures • Assisting with general exam • Method of examination • Inspection • Palpation • Percussion • Auscultation • Mensuration • Manipulation

  25. Positioning and Draping

  26. Positioning and Draping

  27. Positioning and Draping http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs

  28. Assisting with Reproduction and Urinary Specialties Breast Self-Exam (CBE, BSE) Pelvic exam and Pap smear test Cervical Biopsy Prenatal & Postpartum Visits Testicular Self-Exam

  29. Pediatrics http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs Pediatric Vital Signs Maintaining Growth Charts Immunizations Collecting a Urine Specimen from a Pediatric Patient

  30. Assisting with Medical Specialists Skin cancers Nervous system disorders Joint and bone disorders Vascular system disorders Hormonal imbalances Malignant tumors Liver & pancreas disorders Immune system responses Match the following Allergist Cardiologist Dermatologist Endocrinologist Gastroenterologist Neurologist Oncologist Orthopedist

  31. Assisting with Medical Specialties • Allergy testing • Scratch or skin testing • Intradermal allergy test • Patch test

  32. Assisting with Medical Specialists http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs Assisting with a Sigmoidoscopy http://www.youtube.com/watch?v=gFd86AKCWU Assisting with Needle Biopsy

  33. Assisting with Eye Care http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs (Reprinted with permission of Richmond Products, Inc.)

  34. Assisting with Ear Care http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs • Medical assistant • Auditory screening • Administer ear medications • Perform ear irrigations • Assist with diagnostic tests

  35. Assisting with Minor Surgery http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs Medical Assistant’s Role Creating a Sterile Field Performing a Surgical Scrub Donning Sterile Gloves

  36. Assisting with Minor Surgery http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs Non-sterile Assistant Sterile Scrub Assistant Assisting with Minor Surgical Procedures

  37. Assisting with Minor Surgery Cutting and dissecting instruments

  38. Assisting with Minor Surgery Grasping and Clamping Instruments

  39. Assisting with Minor Surgery Retracting, Dilating, and Probing Instruments

  40. Assisting with Minor Surgery Suturing Instruments

  41. Sterilization http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs • Required for all instruments or supplies that • Penetrate the skin • Contact normally sterile areas of the body • Any item used in a sterile field • Prior to sterilization • Sanitize • Disinfect

  42. Autoclave • Primary method of sterilization • Pressurized steam • Use Standard Precautions

  43. Assisting with Minor Surgery Wound care Dressing application Incision and drainage Suture removal http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs

  44. Culture Testing http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs Obtaining a Throat Culture Specimen Performing a Quick Strep A Test

  45. Culture Testing Collecting Sputum Specimen Collecting Wound specimen Preparing Specimens for Transport to an Outside Laboratory

  46. Collecting Urine Specimen Types of testing physical chemical microscopic Visual Examination color/turbidity volume odor specific gravity

  47. Physical Exam of Urine Specimen Reagent Strips Refractometer http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs

  48. Microscopic Examination of Urine Specimens • View elements only visible with microscope • Centrifuge • Spins urine ~ heavier substances settle to the bottom of the tubes • Sediment examined http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs

  49. Collecting Stool Specimen • Screening for colorectal cancer • Fecal occult blood test • Tests for hidden blood • Foods and medication may cause false-positives • Patient instruction important http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs

  50. Cardiology Diagnostic Testing Stress Test Holter Monitor Electrocardiography http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs

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