LibGuides: PMA08-5 Computerized Medical Office: Web Resources

Medical Office

Guidelines for Medical Record Documentation Consistent, current and complete documentation in the medical record is an essential component of quality patient care. The following 21 elements reflect a set of commonly accepted standards for medical record documentation. An organization may use these elements to develop standards for medical record documentation. NCQA considers 6 of the 21 elements as core components to medical record documentation. Core elements are indicated by an asterisk (*).
Patient History & Physical Examination
Covers six steps for making a diagnosis: Anamnesis, Physical Examination, Working Diagnosis, Further Diagnostic Examinations, Final Diagnosis and Therapy.
Therapeutic Communication & Patient Teaching
Covers the role of Medical Assistant, Patient Apprehension, Therapeutic Communication, Patient-centered Listening, prejudice, Therapeutic Environment, Nonverbal Communication, Maslow's Hierarchy of Needs, Coping Mechanisms, Special Needs, Patient Education, Patient-Centered Teaching, Assessment, Strategy, Delivery, Documentation, Evaluation.
Vital Signs
Vital signs include the measurement of: temperature, respiratory rate, pulse, blood pressure and, where appropriate, blood oxygen saturation. These numbers provide critical information (hence the name "vital") about a patient's state of health. In particular, they:

Can identify the existence of an acute medical problem.
Are a means of rapidly quantifying the magnitude of an illness and how well the body is coping with the resultant physiologic stress. The more deranged the vitals, the sicker the patient.
Are a marker of chronic disease states (e.g. hypertension is defined as chronically elevated blood pressure).
Vital Signs: Topic
Vital signs, by definition, are a person’s temperature, pulse, respiration rate, and blood pressure (BP). These signs reflect the status of a person’s circulatory, respiratory, neurological, and endocrine functions.

Basic EKG Refresher
Covers the anatomy, physiology and electrical conduction of the heart. The EKG Waveforms, interpreting the Rhythm strips, Measuring the QRS complex, sinus rhythms, atrial rhythms and ventricular rythms,
Introduction to Specimen Collection
Laboratory tests contribute vital information about a patient's health. Correct diagnostic and therapeutic decisions rely, in part, on the accuracy of test results. Adequate patient preparation, specimen collection, and specimen handling are essential prerequisites for accurate test results. The accuracy of test results is dependent on the integrity of specimens.
Medical X-Ray Imaging Medical imaging has led to improvements in the diagnosis and treatment of numerous medical conditions in children and adults. There are many types - or modalities - of medical imaging procedures, each of which uses different technologies and techniques. Computed tomography (CT), fluoroscopy, and radiography ("conventional X-ray" including mammography) all use ionizing radiation to generate images of the body. Ionizing radiation is a form of radiation that has enough energy to potentially cause damage to DNA and may elevate a person’s lifetime risk of developing cancer. CT, radiography, and fluoroscopy all work on the same basic principle: an X-ray beam is passed through the body where a portion of the X-rays are either absorbed or scattered by the internal structures, and the remaining X-ray pattern is transmitted to a detector (e.g., film or a computer screen) for recording or further processing by a computer.
Order of Draw
Blood Collection Order of the draws, mixing chart and separation.

DailyMed
The DailyMed database contains 140237 labeling submitted to the Food and Drug Administration (FDA) by companies. DailyMed does not contain a complete listing of labeling for FDA-regulated products (e.g., labeling that is not submitted to the FDA). See ABOUT DAILYMED for more information.
Diseases and Conditions
Disease & Conditions are organized A-Z. Each entry has the scientific name, general information, symptoms, transmission, treatment and images. There are also links to the Most searched Diseases and Conditions, Healthy Living, Traveler's Health, Emergency Preparedness, etc.
PDR- Physician's Desk Reference
Lookup Drugs by name, PDR Drug Communications: Alerts, Recalls and approvals, and additional resources.
Recommended Vaccines by Age
Vaccines are available for these 17 dangerous or deadly diseases. Over the years, these vaccines have prevented countless cases of disease and saved millions of lives. Infants, children, adolescents, teens and adults need different vaccinations, depending on their age, location, job, lifestyle, travel schedule, health conditions or previous vaccinations.
Recommended Vaccines by Age
Vaccines are available for these 17 dangerous or deadly diseases. Over the years, these vaccines have prevented countless cases of disease and saved millions of lives. Infants, children, adolescents, teens and adults need different vaccinations, depending on their age, location, job, lifestyle, travel schedule, health conditions or previous vaccinations.

Blood Collection - Routine Venipuncture and Specimen Handling Objectives for the tutorial: Describe and perform the venipuncture process including: Appropriate clothing and protective equipment Ensuring the comfort of the patient Proper patient identification procedures. Proper equipment selection and use. Proper labeling procedures and completion of laboratory requisitions. Order of draw for multiple tube phlebotomy. Preferred venous access sites, and factors to consider in site selection, and ability to differentiate between the feel of a vein, tendon and artery. Patient care following completion of venipuncture. Safety and infection control procedures. Quality assurance issues. Identify the additive, additive function, volume, and specimen considerations to be followed for each of the various color coded tubes. List six areas to be avoided when performing venipuncture and the reasons for the restrictions. Summarize the problems that may be encountered in accessing a vein, including the procedure to follow when a specimen is not obtained. List several effects of exercise, posture, and tourniquet application upon laboratory values.
Emergency Preparedness in Healthcare Practices
Healthcare practices are not immune to emergencies. Many factors can cause or lead to an
emergency, including an accident, a medical event, trauma, a natural disaster, or an act of
violence. These events can occur in healthcare practices just like they can happen in any
other environment. With proper planning and training for emergency situations, healthcare
providers and staff can minimize risks and potentially prevent adverse outcomes.
Parenteral Medications and Preparing Medications from Ampules and Vials Parenteral refers to the path by which medication comes in contact with the body. Parenteral medications enter the body by injection through the tissue and circulatory system. Injection medications are absorbed more quickly and are used with patients who are nauseated, vomiting, restricted from taking oral fluids, or unable to swallow. Parenteral medications can be effective and safe when prepared and administered correctly. However, because they are invasive and absorbed readily and quickly into the body, there are numerous risks associated with administering them (Perry et al., 2014). There are four routes for parenteral medications (also see Figure 7.1). Each type of injection requires a specific skill set to ensure the medication is prepared properly and administered into the correct location (Perry et al., 2014). The four types of injections are: Subcutaneous (SC): This injection places medication/solution the loose connective tissue just under the dermis. Intradermal (ID): This injection places the medication into the dermis just under the epidermis. Intramuscular (IM): This injection places the medication into the body of a muscle. Intravenous (IV): This injection places the medication/solution into a vein through an existing IV line or a short venous access device (saline lock). Medications given by the intravenous route can be given as an IV bolus, as an intermittent (piggyback) medication, or in a large volume continuous infusion.
Surgical Aseptic Technique And Sterile Field
Recommendations for Asepsis for Invasive Surgical Procedures Conducted Outside of Operating Rooms or in Community-Based Healthcare Settings.

Collection of Specimens/Swabs Procedure The purpose of this presentation is to demonstrate the correct procedure for taking a variety of swabs. Please note that policies and procedures may vary in different Trusts. It is essential that you have had training on the specific techniques before performing this skill. It is the personal and professional responsibility of healthcare practitioners to ensure that they are competent to undertake this procedure. Specimens of tissue or fluid are collected when microbiological; biochemical or other laboratory investigations are required to aid diagnosis. The results of such investigations may classify the disease and determine diagnosis and treatment.
Communicating with Older Adults
This special publication provides an introduction to common heuristics (mental shortcuts) and biases (predictable systematic errors in reasoning) that could affect health care decisions made by older adults, health care providers, and caregivers. Select heuristics and biases are illustrated in hypothetical cases involving the use of nonprescription analgesics and the need for recommended immunizations; each case includes communication tips for overcoming the heuristic or bias. The objective is to encourage more productive decision-making conversations with older adults.
Geriatric Assistive Devices:
Disability and mobility problems increase with age. Assistive devices such as canes, crutches, and walkers can be
used to increase a patient’s base of support, improve balance, and increase activity and independence, but they are
not without significant musculoskeletal and metabolic demands. Most patients with assistive devices have never
been instructed on the proper use and often have devices that are inappropriate, damaged, or are of the incorrect
height. Selection of a suitable device depends on the patient’s strength, endurance, balance, cognitive function, and
environmental demands.
Pediatric History & Physical Exam 1. To understand the content differences in obtaining a medical history on a pediatric patient compared to an adult. a. To understand how the age of the child has an impact on obtaining an appropriate medical history. 2. To understand all the ramifications of the parent as historian in obtaining a medical history in a pediatric patient. 3. To understand the appropriate wording of open-ended and directed questions, and appropriate use of each type of question. 4. To develop an awareness of which clinical settings it is appropriate to obtain a complete medical history compared to a more limited, focused history.

Job Search Techniques
Get in the right mind-set, Determine your Job interests and prepare job search documents. Search methods: Online Search and Networking,
Professionalism in the Workplace:
Covers basic traits and practices of successful professionals. Characteristics are character, attitude, excellence, competency and conduct.
Resume Guide CareerOneStop's Resume Guide will help you create a resume that will stand out in today’s job market. You'll find: A step-by-step plan for what to include in your resume Tips to write, format, and polish your resume Resume samples, resume templates Online resume tips, including using tools like LinkedIn and Facebook Professional resume tips Get started by learning why you need a great resume, or choose another topic at left.
Workplace Professionalism
Covers professionalism in the Workplace, the definition, unwritten rules, Unprofessionalism, expectations, Individual Responsibility, Boundaries and Work-Home Balance.
World Health Organization WHO International organization that works with governments and other partners to help combat diseases and keep people healthy. Website provides information on various health topics, resources, and news.

PMA08-5 Computerized Medical Office: Web Resources

Medical Office

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