Medical assistant procedure manual

Medical Assistant Procedure Manual Project Pamela Estep ENGL205-1203A- Technical Writing and Speaking Phase 5IP Abstract This procedure manual was designed to help the medical assistant if they would have a question or happen to need reassuring about a procedure. It is also to be used as a training tool for new staff and current staff. This manual will list both administrative and clinical duties that are to be performed by the medical assistant. This manual will also be updated as new duties come about or old duties are taken out.

This will be your bible for your job here, and you are to follow this manual to keep down any confusion that can come with your job. But if you would still need a clarification on something that is not list in this manual please feel free to contact myself, and I will answer your question and then this question is a common one we will install it to the manual. As all ways we want you to have a pleasant time here with us so feel free to make any suggestion of ways to improve your job. Master Table of Contents Project Outline (phase 1)……………………………………………………………………… 3

Procedure Manual Proposal (phase 1)………………………………………………………… 5 Procedure Manual Outline (phase 1)…………………………………………………………. 6 Procedure Manual Brochure (phase 2)………………………………………………………. 7-8 Procedure Manual Checklist (phase 3)………………………………………………………. 9 Procedure Manual (phase 3)…………………………………………………………………. 10-29 Procedure Manual Quick Reference Guide (phase 4)……………………………………….. Procedure Manual Training Session (PowerPoint) (phase 5)………………………………… Signature page …………………………………………………………………………………………….

Reference page …………………………………………………………………….. Memo Pamela Estep ENGL205-1203A-03 Phase 1 DB2 Professor: Anderson July 15, 2012DoctorMarkesberry, As part of my most resent assessment you ask me to see why there was so much confusion between the medical assistants. You said you had some patients asking why when a different medical assistant takes care of them they do not do the same things as their regular medical assistant. After watching each of the medical assistant for one week and asking each of them different question about how they perform their job, they each gave me a different answer.

After hearing this and what I seen I feel we are in need of a procedure manual. This manual will not let them know what is expected of them but how it is to be performed in this office. With this manual in return all of the medical assistant should perform the same no matter which doctor they are working for. This should also cut down on the confusion with the patients and put then at ease when the medical assistant they are used to taking care of them cannot be there that day. Not only will it comfort the patient it will also cut down on chance of mistakes being made that ould hurt a patient or cost some a life. With this proposal I feel it would be a great benefit for the medical assistant we have now and any new ones in the future. It would give a clear cut of their job definition and job expectation. That would also reduce our liability for mistakes by someone not know 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 foe quick access and each would also have a signature page which each medical assistant would have to sign and that would be put in their personal folders. Once again let me state based on what I have seen and been told by each of the medical assistants I feel this is the only way to give them clear cut instructions on what is expected of each of them and how it is to be done. Thank you, Pamela Estep Doctor Markesberry, As stated in my proposal, the following is a copy of the outline in which I plan to use. As this is tentative outline just let me know if you would like to add anything before anything is set in stone.

I look forward to your input; I hope this is what you are wanting in way of the procedure manual you had in mine. With that said here is the basic outline of the manual. Medical Assistant Manual Outline I. Introduction What the manual is for and a brief overview of the manual. II. Administrative Duties 1. Scheduling and receiving patients. 2. Preparing and maintaining medical records. 3. Performing basic secretarial skills and medical transcription. 4. Handling telephone calls and writing correspondence. 5. Serving as a liaison between the physician and other individuals. 6. Managing practice finances.

III. Clinical Duties 1. Asepsis and infection control. 2. Taking patient histories and vitals. 3. Perform first aid and CPR. 4. Preparing patients for procedures. 5. Assisting the physician with examinations and treatments. 6. Collecting and processing specimens. 7. Performing selecteddiagnostictests. 8. Preparing and administering medications as directed by the physician. As you can see I have included both administrative and clinical duties to be performed, there are many medical assistant out there that think you just take care of a patient but they will see it is much more than that.

Once again feel free of any changes that you want made. A procedure Manual is a must for any job. It provides valuable information about your job and can answer the most common questions. It does not matter the size of your office a procedure manual is there when you need it to refresh your memory or answer your question. With this manual in place we all will be held accountable for our actions and we will perform as a better team that supports each other. The following is my check list for the Medical Assistant procedure manual. 1) To make sure there is a need for the procedure manual.

I will include all the parts that are needed to perform the medical assistant job. I will include the safety risk, and include common legal issues and how to avoid them. 2) I will write a rough draft of this manual and let doctor Markesberry and let the front desk supervisor look it over for any change the need to be made before final draft. 3) I will then have a meeting with the medical assistants and front desk people to go over the manual. At which time I will answer any question about the manual or if there is anything that they would like to see in the manual. ) I will rewrite the manual after I receive the suggestion and answered the question. Once I have done this and send this for approval from upper management. 5) Once I have got the approval I will make a copy for everyone involved and some extra copies for new hires and for people who lose their there will be a master copy which will be kept in the supervisor office. I will then have meeting every two weeks for updates and to go over any problems that might arise. Medical Assistant Procedure Manual for Primary Care Office of Doctor Markesberry Table of Contents

Introduction……………………………………………………………………………………3 Administrative duties Scheduling and receiving patients……………………………………………………………………………………… 4 Preparing and maintaining medical records………………………………………………………5 Performing and Maintaining medical records……………………………………………………. 6 Handling telephone calls and writing correspondence……………………………………………7 Serving as a liaison between the physician and other individuals………………………………… 8 Managing Practice finances………………………………………………………………………. 9 Clinical Duties

Asepsis and infection control……………………………………………………………………10 Taking patient histories and vitals signs……………………………………………………………………………. 11 Performing first aid and CPR……………………………………………………………………12 Preparing patients for procedures……………………………………………………………….. 13 Assisting the physician with examinations and treatments……………………………………… 14 Collecting and processing specimens……………………………………………………………15 Performing selected diagnostic test…………………………………………………………….. 16 Preparing and administering medications as directed by the physician…………………………17 Common

Q&A……………………………………………………………………18 Notes…………………………………………………………………………………………………………………………. 19 Signature page……………………………………………………………………………….. 20 Administrative duties Scheduling and receiving patients Upon arrival to the office the patient will stop at the front desk, once there they will sing in and have a sit. After you call the patient up to the desk at that point you will ask the patient name, DOB, address and phone number. Once you have made sure this is the right patient, you will then ask to see their insurance card.

When they give you the insurance card you need to verify that it is in effect, after that you collect their copay. Upon arrival this is the process: 1. Pt. sign 2. Call pt. to desk 3. Verify DOB, Address, Phone number 4. Confirm appointment. 5. Ask for insurance card, verify it. 6. Collect copay Scheduling appointment can be making an appointment for a doctor in our office to making an appointment for an outside doctor, test, or lab work. Whichever it is you need to make sure of the same information when receiving a patient. With a couple of exception of the patient sign and collecting their copay.

This is the way the process should go: 1. Check the availability date of the appointment. 2. Ask patient if this is a go date and time is right for the patient. 3. Appointment is out our office give them insurance information, DOB, name, and address of the patient. 4. For an outside appointment you will give them the name of the doctor ordering the appointment to be made. 5. Give the patient an appointment card or instruction on where to go the appointment. 6. Then fax all information to the appointment before the patient go’s so they can have a copy.

When making the outside appointment always fax the order and patient information to the office the patient is going that way they have a backup copy beside you call and sitting up the appointment. Then put the information in the chart or on the computer so if there is confusion when the patient get there you have the information at hand. Preparing and maintaining medical records When you receive reports, physician notes from outside offices you need to put these in the patient charts. But before you can put them in the charts you need to let the physician know the reports or progress notes have come in.

That way if some is abnormal the doctor can call the patient, once the doctor has sign the reports or notes you then need to place them in the charts. If they are still using paper charts you will need 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 move the report to the right chart in the right place. Please use the following steps: 1. Sort all the reports and physician notes. 2. Place a received date stamp on them. 3. Then give to the doctor for review. 4. After receiving they back sort them by name and date. 5.

Scan them in the charts. 6. After all reports and notes have be scanned in charts and filed shred the documents. 7. Check that all orders have been signed and all doctors’ notes have been signed. At the end of the day or at lunch you need to fill all charts that are done and pull the next patient charts do to come in. This needs to be done every day to keep within the HIPPA and Medicare standards. If the doctor tells you to call a patient and give them their results that is the only time you can do so. You cannot otherwise and never tell the front desk people to do this they are not trained to do this and it is unethical.

Performing basic secretarial skills and medical transcription From time to time you may need to transcribe doctor’s dictations. If the patient would need and copy of the visit 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 tell you to right up something and he will sign it after you typed it. However it is done you must get 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 another copy later.

Handling telephone calls and writing correspondence When receiving a phone call from a patient you need to get 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 help them. After the patient tells you want they need right it down, never just try to keep it in your head. Before you can do whatever the patient called for you might get interrupted and forget what it was or who the patient was. This is very important 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 machine or with any other person. When you call and you get 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 applies to leaving 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 sending a correspondence to another physician always be professional 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 read 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 mean or what did he say.

The patient does not always understand the doctor so you knowledge of medical terminology is a must. Because you have to translate the medical meaning 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 might 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 first person they see, you are setting the impression for the office, so always be professional. Managing practice finances This is a vital part of any office, if nomoneyis coming 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 deposit. You will also have to collect any money due on medication that is picked 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, amount of cash in bill and coins. Then you list all checks one at a time on a separate line; put the last name from the check and the amount 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 clean and sterilize all instruments, you are to wipe down all the patient come into contact with in the room after each patient. You are to wear gloves when handling any body fluids or cleaning any open wound. You are to change the trash after any patient that has a procedure done or after any dressing changes. If giving a female examine you need to change the trash 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 cleaning the room 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 next day. If you have a patient coming 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 waiting room they do not spread anything to the other patients. If the patient has the chicken pox bring them back as soon as they get to the office do not let them wait in the waiting room.

After you see them clean and sterilize the room so you are not exposing another patient to the virus. If helping with a procedure 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 yourfamily. Taking patient histories and vital signs Taking patient history you need to be very through this can give you clues to what might be going on with your patient. It all so let you know will they are at risk of getting in the future. You need to ask about their parents, brothers and sisters, grandparents.

You need to ask about child hood illness, past surgical history, any know drug allergy, anyfoodallergy, 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. Pulse 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 pulse is regular if you never touch your patient you will miss thing that can hinder the patient treatment. Performing first aid and CPR

When 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. Keep the patient warm and conformable. Give oxygen 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 none 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 certification 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 patient 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 going to happen and when it is going to happen.

Answer any question they have, if you don’t 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 beginning 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 help the patient get ready, by undressing or any preparation that need to be done before the procedure.

Try to keep thing light between you and the patient this helps them relax. Once the procedure is done help them get dressed or help 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. Tell them what you are doing. Assist the doctor any way possible 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 easy the process helps the patient and the physician. Keep any exposed areas covered until the doctor is ready to examine that area. 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 discharge information go over it with the patient. Collecting and processing specimens

When 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. Let 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 bandage 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 cold 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 as EKG’s 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 connect the machine. Once you have this done tell the patient to hold still and preform the test. After you are done unhook the leads and remove 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 allergic 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. Make 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 Guide 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 transcription. 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. Talk 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. Total 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 them. ) Performing first aid and CPR. Use serial dressings for all first aid dressing. Don’t remove any objects without doctor knowing. Use PPI. Check your ABC make sure they are absent before doing CPR. Don’t 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, 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. Process all specimens as needed to preserve 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 the 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 it’s less than the base copay. 2) What if a teenage child comes in for an appointment and they did not bring their parents?

You can’t not treat the patient, without written permission or the parent being there. 3) What if the patient would call in to request a refill on their pain 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, plus 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 Session (power point)