Chapter 6: Developing In- Office Screening Skills

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College Clinical Medical Assisting (Clinical Medical Assisting) Flashcards on Chapter 6: Developing In- Office Screening Skills, created by La'Shae on 07/15/2015.
La'Shae
Flashcards by La'Shae, updated more than 1 year ago
La'Shae
Created by La'Shae almost 9 years ago
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Question Answer
Anticipation Skills the ability to know what the provider needs without having to ask
Medical Assistant Boundries -diagnostic testing w/ physicians order -patient preparation -screener -chief complaint -patient histories -vital signs
In Office Screenings -obtain the chief complaint -update current med list -update allergy status -perform and document vital signs
Chief Complaint -the complaint or reason that prompted the patient to seek medical attention -subjective information
History of the Present Illness (HPI) a series of symptoms that are related to the patient's complaint
Breasts -pain, tenderness, swelling, odor, change in size, history of breast disease -Disrobing: remove all clothing from the waist up -vitals: blood pressure (never take on same side as a mastectomy), weight -Supplies: culture supplies if drainage is present
Cardiovascular -difficulty breathing, shortness of breath, chest pains or pressure, heart palpitations, nausea or vomiting -Disrobing: remove all clothing waist up -All Vitals - crash cart, AED, ECG, oxygen, IV materials
Ears hearing deficits, ringing in ear, pain or discharge, build up of earwax, foreign body in ear -no disrobing -Vitals: temperature and blood pressure, weight, maybe audiometry -Supplies: Otoscope, ear irrigation equipment and solution, gauze
Eyes visual disturbances, double vision. light sensitivty, excessive tearing, drainage, blind spots, foreign body in eye -no disrobing -vitals: blood pressure. weight, visual acuity testing -Supplies: cycloplegics, fluorescain dye, sterile swabs, gauze, pen light, opthalmoscope, and antibiotic drops
Documenting Chief of Complaint -Location: general location of symptoms -Amount -Color: important for body fluids -Size: large, small -Pain: numeric scale or face scale -Duration or Date of Onset: the period of time the symptoms have occured -Related Symptoms: -current med list -listed drug allergies -closing, professional, signature
Standing Orders a list of written orders -developed by the provider for procedures that were to be performed when the patient complained of specific symptoms
Provider's Role -expanding HPI to include exact location, quality, severity, duration, timing, context, modifying factors, and associated symptoms -performing a review of symptoms -performing an examination, and document findings
Progress Note -date and time -reason for the visit -current symptoms -patient's compliance or noncompliance to follow home care instructions -physical observations -closing signature
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