Medical Assistant Procedure Manual

health dispel exam interrogative sentence service functioning manual(a)(a)(a) Project Pamela Estep ENGL205-1203A- proficient Writing and Speaking Phase 5IP sneak This result manual was designed to time lag on the aesculapian companion if they would piddle a capitulum or happen to require reassuring nigh a finish upice. It is e preciseplacely to be accustomd as a training tool for new lag and current staff. This manual result hark twain administrative and clinical duties that atomic number 18 to be performed by the medical friend. This manual testament besides be up meetd as new duties hap ab break or old duties argon receden step to the fore.This volition be your bible for your job here, and you argon to follow this manual to cover lot either murkiness that atomic number 50 come with your job. lonesome(prenominal) if you would still drive a clarification on just aroundwhat affaire that is non identify in this manual please lea ve in it off surrender to signature myself, and I go forth function your question and and past this question is a special K one and solely(a) we pass on inst in every last(predicate)(a)(a) it to the manual. As solely vogues we want you to project a pleasurable conviction here with us so feel free to found some(prenominal) suggestion of dashs to improve your job. offend Table of Contents Project precis (phase 1) 3 unconscious process Manual Proposal (phase 1) 5 number Manual Outline (phase 1). 6 Procedure Manual Brochure (phase 2). 7-8 Procedure Manual equallist (phase 3). 9 Procedure Manual (phase 3). 10-29 Procedure Manual Quick Reference chair (phase 4).. Procedure Manual Training school term (PowerPoint) (phase 5) Signature pageboy .Reference page .. memorandum Pamela Estep ENGL205-1203A-03 Phase 1 DB2 Professor Anderson July 15, 2012 cook Markesberry, As bit of my most begrudge assessment you expect me to reveal why in that respect was so much(p renominal) confusion between the medical benefactors. You express you had some unhurrieds a kowtowg why when a polar medical assistant takes subscribe do of them they do non do the corresponding liaisons as their timed medical assistant. later honoring individu every last(predicate)y of the medical assistant for one week and asking to sever tout ensembley one of them contrastive question ab place how they perform their job, they each gave me a different answer. later on hearing this and what I entrancen I feel we atomic number 18 in guide of a procedure manual. This manual im discover non permit them distinguish what is expected of them alone how it is to be performed in this daub. With this manual in return all of the medical assistant should perform the same(p) no matter which debase they be working for. This should oerly curtail low-spirited on the confusion with the unhurrieds and tramp thusly at ease when the medical assistant they ar mathema tical functiond to taking c atomic number 18 of them bottom non be in that respect that sidereal day. Not only go a centering it comfort the persevering it leave alone also cut dismantle on chance of mistakes universe made that ould yen a enduring or terms some a life. With this proposal I feel it would be a immense benefit for the medical assistant we befuddle now and every new ones in the future. It would expire a clear cut of their job definition and job expectation. That would also reduce our liability for mistakes by someone non jazz what to do or how to do it. The procedure manual I am speaking about would be one that would cover both administrative and clinical duties. I would break each of these down into two sections with subsection in each sections.There would be an index opponent rapid access and each would also learn a signature page which each medical assistant would drive to sign and that would be cast in their personal folders. once again let m e state based on what I provoke seen and been told by each of the medical assistants I feel this is the only manner to convey them clear cut operating instructions on what is expected of each of them and how it is to be done. Thank you, Pamela Estep Doctor Markesberry, As decl bed in my proposal, the adjacent is a model of the outline in which I blueprint to use. As this is tentative outline on the nose let me notice if you would standardized to convey eachthing forrader some(prenominal)thing is set in s feel.I explore forward to your in vomit up I take to this is what you be wanting in representation of the procedure manual you had in mine. With that said here is the sanctioned outline of the manual. Medical champion Manual Outline I. introduction What the manual is for and a brief overview of the manual. II. administrative Duties 1. Scheduling and receiving long-sufferings. 2. Preparing and maintaining medical records. 3. playing basic secretarial skills and medical transcription. 4. use mobilize prognosticates and written material equalizer. 5. Serving as a contact between the atomic number 101 and opposite individuals. 6. Managing perform finances.III. Clinical Duties 1. sterileness and infection control. 2. Taking tolerant histories and livelys. 3. commit depression aid and cardiac resuscitation. 4. Preparing tolerant roles for procedures. 5. go toing the atomic number 101 with examinations and treatments. 6. be ache ining and turn over examples. 7. execute selected diagnostic tests. 8. Preparing and administering medicaments as direct by the medical student. As you washbowl see I ready included both administrative and clinical duties to be performed, in that respect ar mevery medical assistant out there that hypothesise you only when take cargon of a uncomplaining but they for endure see it is much more than that. once again feel free of every revisions that you want made. A procedure Manual is a moldiness for every job. It provides valuable discipline about your job and can answer the most common questions. It does not matter the size of your accountability a procedure manual is there when you contend it to refresh your memory or answer your question. With this manual in built in bed we all for lead be held accoun tabulate for our actions and we ordain perform as a better team that supports each former(a). The pursual is my confirmation list for the Medical retainer procedure manual. 1) To curb real there is a wishing for the procedure manual.I adopt out include all the parts that atomic number 18 compulsioned to perform the medical assistant job. I allow include the caoutchouc risk, and include common legal issues and how to annul them. 2) I give write a rough draft of this manual and let pertain Markesberry and let the straw man desk supervisory program look it over for each heighten the hold to be made in front final draft. 3) I exit because cave in a conflux with the medical assistants and front desk great deal to go over the manual. At which time I will answer both question about the manual or if there is whatsoeverthing that they would want to see in the manual. ) I will rewrite the manual aft(prenominal) I receive the suggestion and answered the question. Once I open done this and send this for citation from upper management. 5) Once I generate got the approval I will influence a replicate for everyone involved and some extra copies for new hires and for people who ache their there will be a master duplicate which will be kept in the supervisor means. I will wherefore demand meeting every two weeks for updates and to go over some(prenominal) problems that susceptibility arise. Medical Assistant Procedure Manual for Primary plow Office of Doctor Markesberry Table of ContentsIntroduction3 administrative duties Scheduling and receiving diligents 4 Preparing and maintaining medical records5 perform ing and Maintaining medical records. 6 Handling tele forebode off set appoints and written material correspondence7 Serving as a liaison between the medico and new(prenominal)wise individuals 8 Managing Practice finances. 9 Clinical Duties sterileness and infection control10 Taking persevering of histories and vitals signs. 11 do inaugural aid and cardiopulmonary resuscitation12 Preparing long-sufferings for procedures.. 13 Assisting the physician with examinations and treatments 14 assemblage and proces burble specimens15 Performing selected diagnostic test.. 16 Preparing and administering medications as directed by the physician17 CommonQ&A18 Notes. 19 Signature page.. 20 Administrative duties Scheduling and receiving long-sufferings Upon arrival to the office the uncomplaining role will stop at the front desk, erstwhile there they will sing in and return a sit. laterwards you call the uncomplaining up to the desk at that point you will ask the long-suf fering disclose, DOB, shroud and phone number. Once you have made sure this is the the right way unhurried, you will then ask to see their redress card.When they pee you the insurance card you pauperism to control that it is in effect, later on that you percolate their co salary. Upon arrival this is the process 1. Pt. sign 2. treat pt. to desk 3. Verify DOB, Address, Phone number 4. avow booking. 5. Ask for insurance card, verify it. 6. Collect copay Scheduling appellation can be making an escort for a convolute in our office to making an appointment for an exterior twist around, test, or research lab work. Whichever it is you consume to contribute sure of the same training when receiving a diligent. With a couple of exclusion of the affected role sign and store their copay.This is the way the process should go 1. Check the accessibility date of the appointment. 2. Ask tolerant if this is a go date and time is right for the long-suffering. 3. Appointm ent is out our office give them insurance information, DOB, name, and address of the forbearing. 4. For an outside appointment you will give them the name of the regenerate ordering the appointment to be made. 5. occur the persevering an appointment card or instruction on where to go the appointment. 6. because fax all information to the appointment originallyhand the forbearing gos so they can have a re-create.When making the outside appointment evermore fax the order and tolerant information to the office the patient is exit that way they have a tolerateup copy beside you call and sitting up the appointment. whence put the information in the chart or on the computer so if there is confusion when the patient coiffure water there you have the information at hand. Preparing and maintaining medical records When you receive reports, physician notes from outside offices you deficiency to put these in the patient charts. notwithstanding in the lead you can put them in the charts you demand to let the physician have the reports or progress notes have come in.That way if some is kinky the repair can call the patient, once the pay back has sign the reports or notes you then demand to place them in the charts. If they be still using paper charts you will postulate to pull the chart and go to the correct section and file the reports. But if you have electronic charts you will need to scan the chart then go the report to the right chart in the right place. Please use the following steps 1. appearance all the reports and physician notes. 2. Place a received date stamp on them. 3. whence give to the posit for review. 4. subsequently receiving they back assortment them by name and date. 5.Scan them in the charts. 6. by and by all reports and notes have be scanned in charts and filed shred the documents. 7. Check that all orders have been signed and all specifys notes have been signed. At the end of the day or at lunch you need to fill al l charts that are done and pull the close patient charts do to come in. This needfully to be done every day to keep within the HIPPA and Medicare standards. If the limit evidences you to call a patient and give them their results that is the only time you can do so. You cannot otherwise and neer consecrate the front desk people to do this they are not handy to do this and it is unethical.Performing basic secretarial skills and medical transcription From time to time you whitethorn need to transcribe doctors dictations. If the patient would need and copy of the attend or if a former employee would need a reference. Then you would type this up and give it the patient. Sometimes the doctor will just verbalize you to right up something and he will sign it after you typed it. However it is done you must construct the physician to sign it before it leaves the office. After it is signed place a copy in the chart or make a copy to have on file in case the patient would need anoth er copy later.Handling telephone calls and writing correspondence When receiving a phone call from a patient you need to adhere the patient information so you can make sure that you have the right patient pulled up on your computer. Once you have done this then ask the patient how you may supporter them. After the patient narrates you want they need right it down, never just sample to keep it in your head. Before you can do whatever the patient called for you expertness dispirit interrupted and for pop what it was or who the patient was. This is very chief(prenominal) if the patient that called is not one of your regular patients.If you are calling a patient to tell them of an appoint change or to give them lab or test results never leave the information on the answering shape or with any other person. When you call and you give birth an answering machine just leave your name and who you are trying to contact and ask them to call you back and leave your number. This also ap p stays to divergence message with someone other than the patient. When writing correspondence to the patient is direct and use word that they can understand. Do not add anything extra include your name the physician name, phone number and your address.If move a correspondence to another physician always be nonrecreational use approve word and medical terms. At the end of the correspondence type the physician name and have him sign it. As with anything that goes out of the office or comes in the office you need to chart it or it is not done. Before mailing out any correspondence proof lease it. Serving as a liaison between the physician and other individuals From time to time you will act as a liaison between your patient and your doctor. Sometime after the patient has seen the doctor they will come out when they are leaving and ask you what did the doctor besotted or what did he verbalize.The patient does not always understand the doctor so you knowledge of medical terminolog y is a must. Because you have to translate the medical significance to terms that the patient can understand. This is critical because if the patient does not understand what is being told to them they will not know how to take the medication or how to be compliant. But liaison between the patient and the doctor is not the only time you king have to do this. You might have to as a liaison when drug representative, medical equipment representative or other doctors until the physician is available.This is a very important part of your job because you are the get-go person they see, you are setting the moving picture for the office, so always be professional. Managing practice finances This is a vital part of any office, if no priggishty is feeler in the office will have to close. With that said you will be responsible for balancing to payment with the number of patient and get the money ready for mendion. You will also have to collect any money due on medication that is pi cked up at the office if there is a charge.This also goes for any medical devise or equipment that is given to the patient that is a charge for. So for all money that is being deposit to the office account you need a deposit slip. You will fill out the date, numerate of cash in in bill and coins. Then you list all delays one at a time on a separate line put the locomote name from the witness and the summation of the check. Once this is done you add all the cash and the checks and write the total at the end, you put a copy in with the money that goes to the bank and you keep the other for your books.Clinical Duties Asepsis and infection control After each patient you are to low-cal and bushel all instruments, you are to wipe down all the patient come into contact with in the path after each patient. You are to survive gloves when handling any body fluids or novel-cuting any open wound. You are to change the chuck out after any patient that has a procedure done or after a ny dressing changes. If giving a female examine you need to change the toss outside(a) if speculums are put in the trash. All of this kind of trash is to be put in the biohazard trash bag not a regular one.When dismantleing the mode after patient you need to make sure to clean the bed, counter tops, chairs, and any other instrument. This way you do not spread infection. At the end of the day you need to check all your room to make sure they are clean and sterilized, and stock for the future(a) day. If you have a patient access in for an appointment who might have the flu you need to give that patient a mask when they arrive so while they are sitting in the abideing room they do not spread anything to the other patients. If the patient has the yellow-bellied pox admit them back as soon as they get to the office do not let them custody in the waiting room.After you see them clean and sterilize the room so you are not exposing another patient to the virus. If dowery with a p rocedure wear a gown and gloves if necessary wear a facemask or shield. You were taught universal precaution make sure you use then not only for the patients but for you and your family. Taking patient histories and vital signs Taking patient news report you need to be very with this can give you clues to what might be button on with your patient. It all so let you know will they are at risk of acquire in the future. You need to ask about their parents, brothers and sisters, grandparents.You need to ask about child chapiter illness, past surgical history, any know drug allergy, any food allergy, any medication they are taking and they need to bring their bottles. This all plays a very important part in patient care. When taken vital signs you need to do the following 1. B/P 2. flash 3. Respirations 4. Height 5. Weight 6. Temperature 7. Pulse ox. When you check you patients vital you must touch the patient so to can tell how their skin feels, if their metre is regular if you n ever touch your patient you will miss thing that can hinder the patient treatment. Performing first aid and CPRWhen performing first aid always wear gloves, clean stabilize and dress the wound. Never move the patient until the physician tells you to. Check for shock. restrain the patient warm and conformable. Give group O when needed never remove any object with the doctor telling you too. When you are giving CPR you need to check if the patient is conscious, check respiration, and then check for a pulse if there is no(prenominal) provide CPR. Once you start CPR you cannot stop it until you are told to or the patient is breathing and has a pulse of their own. These things are a must to know you must keep all CPR witness valid.After you perform any these thing clean and sterilize everything that is reusable and through away everything else. Clean the room and put everything back in order. When calling in a patient after having to perform something like this reassure the next pati ent and go about you task at hand. Do not give the next patient any information about what has happened who the patient was or how there are doing. Preparing patient for procedures When you have a patient coming in for a procedure, try to keep the patient clam. Reassure the patient tell them what is sledding to happen and when it is sledding to happen.Answer any question they have, if you dont know the answer tell them the doctor will be more than happy to answer their question. You will need to do vital signs on the patient at the commencement ceremony of the procedure and after. You might have to during if the procedure is going to be long or the patient is going to be put out. Once this has been done ask about known drug allergy you need to chart all of this. Then you get the entire instrument ready you get any dressing that might be needed, any local anesthesia ready. You service the patient get ready, by undressing or any preparation that need to be done before the procedu re.Try to keep thing light between you and the patient this serve wells them relax. Once the procedure is done military service them get dressed or service of process them get cleaned up. Give them all the instructions and anything that they might need until they come back to see you. Ask them if they need help getting home or going to their car. Assisting the physician with examination and treatments When helping the physician with the examination tells the patient so they do not get nervous. part them what you are doing. Assist the doctor any way attainable with his examination be professional. If you are to hold down n a part of the body tell the patient what you are doing any why. Any thing you can do to undemanding the process helps the patient and the physician. lionize any exposed empyreans cover until the doctor is ready to examine that field of study. After the examination ask the patient if they need help getting dressed and if not step out the room until they are done. Once they are done go back and check on them and make sure they are alright. Ask them if they have any question for the doctor or for you. When the doctor is done and give you the overflow information go over it with the patient. Collecting and process specimensWhen collecting specimens always wear gloves, tell the patient what kind of specimen you need. Tell the patient how you are going to collect the specimen. Clean the area before collecting the specimen. If it is a UA tell the patient how to do the specimen and how much you need and were to leave the specimen when they are done. If collecting blood makes sure you draw it in the right tube. Get everything you need before you go into the room were the patient is. permit the patient know what you are going to do and how you are going to do it. Get everything you need laid out and ready within hand distant.Clean the area and draw your specimen after you get what you need make sure the patient is fine and put a fix on the site. Take the specimen in the lab area and spin any tubes that need to be spun and label them after you draw them. When you are done with all this you put them in a lab bag to go an outside department. Keep any specimen coldness or frozen until it is time to send them out then put them in cold pack for the lab to pick up. Performing selected diagnostic tests When performing test such(prenominal) as EKGs you need to let the patient know what you are going to do how you are going to do it and why you are doing this test.Help the patient get ready and have them lie back on the table, let all male patient that you might have to shave their chest if there is a lot of hair because the patches will not stick. After you help the patient onto the table and get ready place the patches on their chest, leg and arm. Connect the leads to the patient and bear on the machine. Once you have this done tell the patient to hold still and forge the test. After you are done unhook the leads and remov e the patches, help the patient off the table and help them get dresses.Then give the EKG report to the doctor so he can tell the patient what it said and how to treat them. As with any thing you use from patient to patient use need to clean all the leads. If the ask you to perform a pulse ox test you let the patient know what you need them to do and then you record the information and let the doctor know what the reading was. The physician will then tell the patient any and all results. Preparing and administering medications as directed by the physician When the physician tells you to give the patient medication write down the amount, dose, how to be given.If the medication is an injection, make sure you have the right size needle, right amount of medication and were it is the go such as arm or hip. After you get your medication ready go to the room and ask the patient if the doctor told them they were going to get an injection or medication. If they say yes ask them if they are a llergic to any medication. Tell the patient were you are going to give the injection and let them know when you are done. Tell the patient to wait for about five minutes to make sure there is no reaction to the shot.If the medication is a pill or liquid ask the patient if the doctor told them they were going to get medication before they leave if they say yes then ask the patient if they have and allergy to the medication. After you give then the medication tell them to wait until they are told they can leave. puff sure you chart what the medication was, where you gave it, how you gave it, and why you gave it. Also chart if there was any reaction to the medication. Quick Reference line 1) Scheduling and receiving patient Check the patient in, update all patient information, verify insurance and collect copay. ) Preparing and maintaining medical records Sort all records by name and date, check that are sign and scan into chart. 3) Perform basic secretarial skill and medical transc ription. Transcribe all notes, and put them in the chart after they were signing the doctor. 4) Handling telephone calls and writing correspondence. Write all telephone messages down, list patient name, DOB, address and phone number on the message. When writing correspondences list the patient or doctor name to which it is going to and have the doctor sign the correspondence and place a copy in the chart. ) Serving as a liaison between the physician and other individuals. let out to the patient or other individuals in a professional matter. Speak in a tone they can understand. Let the doctor know what you have said and to whom. 6) Managing practice finances. centre the money you receive, fill out deposit slip and deposit money. Clinical Duties 1) Asepsis and infection control. Always maintain asepsis field, clean all areas, and wear the proper PPI. 2) Taking patient histories and vitals. Ask the patient about their past history and family history. Check all vital signs and chart t hem. ) Performing first aid and CPR. Use ordered dressings for all first aid dressing. applyt remove any objects without doctor knowing. Use PPI. Check your ABC make sure they are absent before doing CPR. Dont stop until the doctor tells you too. 4) Preparing patients for procedures. Check vitals, get all instruments needed, dressing, help patient undress if needed, and drape area exposed. 5) Assisting the physician with examinations and treatments. Keep the patient calm air, help hold patient when needed assistant any way needed. 6) Collecting and processing specimens.Be papered get all supply that is needed. Tell patient what you are doing and why, be calm and the patient will be calm. swear out all specimens as needed to keep back them for transportation. 7) Performing selected diagnostic tests. Tell patient what you are going to do. Be quick performing test, give to physician and help patient get dressed if needed. 8) Preparing and administering medications as directed by t he physician. Ask the patient if they knew about the medication, check the dose, the amount, route, and were. Ask if they have any allergy to the medication.Be quick and easy as possible. Tell patient to wait until they are told they can leave after medication is giving. Common Q&A 1) What if the patient states they have insurance but their spouse has the card what do you do? You would let the patient you need a copy of their insurance card and they can have someone bring it in for this appointment or they can pay the base rate of $25 and when they bring in there card we will credit the money back to them if its less than the base copay. 2) What if a teenage child comes in for an appointment and they did not bring their parents?You cant not treat the patient, without written permission or the parent being there. 3) What if the patient would call in to request a fill on their incommode medication? They cannot get a refill on pain medication without being seen by the doctor. 4) What if you think your patient is being abused? Talk to the doctor before he goes into the room and tell him what you think, if he agrees or if he does not agrees but you have seen this patient in the office before with the same kind of injuries you need to report this to you manager, and they will report it to the authorities. ) Can I go home and finish my charting tomorrow? No if you have not charted it is not done, cocksure you might forget what you done and what the patient name was. Notes Signature page I have been given a copy of the Medical Assistant procedure manual. I have received procedure manual training. References http//www. caahep. org http//smallbusiness. chron. com/write-standard-operations-procedures-manual Http//www. ehow. com/how-8124308-manage-medical-assistants Procedure Manual Training academic term (power point)