Medical Terminology PDF

Foundational Knowledge and Basic Science: Medical Terminology Medical Terminology Learning medical terminology might seem as daunting as learning another language. In a way, it is another language. When toddlers first start speaking actual words, they do not yet know what g...

Foundational Knowledge and Basic Science: Medical Terminology Medical Terminology Learning medical terminology might seem as daunting as learning another language. In a way, it is another language. When toddlers first start speaking actual words, they do not yet know what geography, philanthropy, or accountability mean. But with experience in listening and speaking, they learn to use and understand more words. They later notice connections among words—their prefixes, roots, and suffixes. As their vocabulary continues to expand, children usually master communication in their native language. Medical assistants become fluent in medical terminology in much the same way, with one distinct advantage. They will first learn the basics in coursework and with learning activities such as this module. Here are the most common terms, abbreviations, acronyms, and symbols needed to begin to navigate communication in this new career. Learning how to dissect some terms into their prefixes, roots, and suffixes can also expand understanding of terminology much faster than learning each word individually, fast-tracking to mastery in medical terminology. Common Abbreviations, Acronyms, and Symbols Medical assistants see and use many abbreviations (a term that will refer here to symbols as well) in everyday practice. The Joint Commission (TJC) and the Institute for Safe Medication Practices (ISMP) have put some abbreviations on their “Do Not Use” and “Error-Prone Abbreviations” lists. Avoiding these abbreviations is essential because of their potential for misunderstanding and medical errors. The following table includes many abbreviations that should not be used. (For the full lists, go to The Joint Commission and ISMP websites.) DO NOT USE USE INSTEAD MS, MSO4 Morphine MgSO4 Magnesium sulfate Abbreviated medication name Full medication name Nitro Nitroglycerin u, U, IU Units ©2023 Assessment Technologies Institute, L.L.C 1  Foundational Knowledge and Basic Science: Medical Terminology DO NOT USE USE INSTEAD x3d mcg or microgram cc mL Apothecary units Metric units od, O.D., OD Daily or intended time of administration q.d, qd, Q.D, QD, q1d, i/d Daily q.o.d., QOD Every other day Q6PM 6 p.m. daily TIW, tiw 3 times weekly HS half-strength, bedtime (hour of sleep) SC, SQ, sub q subcutaneously IN intranasal IJ injection OJ orange juice @ at &, + and / per AD, AS, AU right ear, left ear, both ears OD, OS, OU right eye, left eye, both eyes D/C, dc, d/c discharge or discontinue ©2023 Assessment Technologies Institute, L.L.C 2  Foundational Knowledge and Basic Science: Medical Terminology Abbreviations Many other abbreviations are facility-specific but not universal. For example, one hospital might call its storage and processing area for medical products “central supply,” while another might call it “materials management.” So, “CS” has no meaning (or a different meaning) in Hospital B, and “MM” has no meaning (or a different meaning) in Hospital A. Likewise, Hospital A calls the surgery area the operating room (OR), while Hospital B calls it the surgical suite (SS). Yet another hospital uses “SS” to mean its department of social services. Many acronyms go back to long-outdated usage. “Emergency room” became common parlance when there was literally one room—an emergency or accident room. Even though today’s hospitals have an enormous emergency department (ED), “ER” is still in prevalent use today. Other terminology changes over time. What was once the recovery room (RR) is now the post-anesthesia care unit (PACU). There are many common abbreviations that reflect current clinical practice and are primarily universal. Providers use many of these when writing orders, often on prescription pads, for diagnostic tests and procedures. Here is a list of many of those common abbreviations. Common Abbreviations and Acronyms ABBREVIATION/ ABBREVIATION/ ACRONYM MEANING ACRONYM MEANING Abd Abdomen C Celsius ABGs Arterial blood gases C&S Culture and sensitivity a.c. Before meals Ca Calcium; cancer ACLS Advance cardiac life support CABG Coronary artery bypass graft Ad lib As desired CAD Coronary artery disease ADHD Attention deficit CBC Complete blood count hyperactivity disorder AKA Above-the-knee amputation CC Chief complaint AMA Against medical advice CDC Centers for Disease Control and Prevention ASA Aspirin cm Centimeter ©2023 Assessment Technologies Institute, L.L.C 3  Foundational Knowledge and Basic Science: Medical Terminology ABBREVIATION/ ABBREVIATION/ ACRONYM MEANING ACRONYM MEANING ASAP As soon as possible CMS Centers for Medicare and Medicaid Services BE Barium enema CNS Central nervous system BKA Below-the-knee amputation CP Chest pain BM Bowel movement CPR Cardiopulmonary resuscitation BMI Body mass index c/o Complains of BP Blood pressure COPD Chronic obstructive pulmonary disease BPH Benign prostatic Csf Cerebrospinal fluid hypertrophy BPM Beats per minute CT Computed tomography BRP Bathroom privileges Cv Cardiovascular BSA Body surface area CVA Cerebrovascular accident (stroke) BUN Blood urea nitrogen CXR Chest x-ray Bx Biopsy d Day c̄ With D&C Dilation and curettage D/C, dc Discharge, discontinue HIV Human immunodeficiency virus DM Diabetes mellitus HPV Human papillomavirus DNR Do not resuscitate HTN Hypertension DOB Date of birth Hx History DTap Diphtheria, tetanus, and I&D Incision and drainage acellular pertussis vaccine ©2023 Assessment Technologies Institute, L.L.C 4  Foundational Knowledge and Basic Science: Medical Terminology ABBREVIATION/ ABBREVIATION/ ACRONYM MEANING ACRONYM MEANING Dx Diagnosis I&O Intake and output ECG, EKG Electrocardiogram ICU Intensive care unit ED Emergency department IUD Intrauterine device EEG Electroencephalogram K Potassium ENT Ear, nose, and throat KUB Kidneys, ureters, bladder F Fahrenheit L Liter or left FBS, FBG Fasting blood sugar/glucose lb Pound f/u Follow up LLE Left lower extremity FUO Fever of unknown origin LLL Left lower lobe Fx Fracture LLQ Left lower quadrant GI Gastrointestinal LMP Last menstrual period GTT Glucose tolerance test LUE Left upper extremity gtt Drop LUQ Left upper quadrant GU Genitourinary Mg/dl Milligrams per deciliter GYN Gynecology, gynecologist MI Myocardial infarction H, hr Hour mL Milliliters Hct Hematocrit MM Mucous membrane HEENT Head, ears, eyes, nose, mm Hg Millimeters of mercury throat HF Heart failure MRI Magnetic resonance imaging Hgb Hemoglobin MS Multiple sclerosis ©2023 Assessment Technologies Institute, L.L.C 5  Foundational Knowledge and Basic Science: Medical Terminology ABBREVIATION/ ABBREVIATION/ ACRONYM MEANING ACRONYM MEANING HIPAA Health Insurance Portability N/V Nausea/vomiting and Accountability Act NB Newborn RLL Right lower lobe NG Nasogastric RLQ Right lower quadrant NKA/NKDA No known allergies/No R/O Rule out known drug allergies NPO Nothing by mouth (nil per ROM Range of motion os) NS Normal saline RT Respiratory therapy/therapist NSAID Nonsteroidal anti- RUE Right upper extremity inflammatory drug OB Obstetrics RUQ Right upper quadrant OC Oral contraceptive Rx Prescription OOB Out of bed s̄ Without OP Outpatient SOB Shortness of breath OT Occupational Stat Immediately therapy/therapist OTC Over-the-counter STI Sexually transmitted infection PA Posteroanterior, physician Sx Symptoms assistant p.c. After meals (post cibos) T&A Tonsillectomy and adenoidectomy PE Physical examination, TB Tuberculosis pulmonary embolism ©2023 Assessment Technologies Institute, L.L.C 6  Foundational Knowledge and Basic Science: Medical Terminology ABBREVIATION/ ABBREVIATION/ ACRONYM MEANING ACRONYM MEANING PID Pelvic inflammatory disease TIA Transient ischemic attack PMS Premenstrual syndrome Tx Treatment PO By mouth UA Urinalysis PRN As needed URI Upper respiratory infection PT Physical therapy/therapist UTI Urinary tract infection pt Patient VS Vital signs R Right WBC White blood cell RA Rheumatoid arthritis WNL Within normal limits RBC Red blood cell YO, y/o Years old RLE Right lower extremity Acronyms and Symbols Some medical symbols have fallen out of use because of their tendency toward misinterpretation, especially in handwriting. Some of those are on the “Do Not Use” and “Error-Prone Abbreviations” lists. Examples are the symbols for “greater than” and “less than” (> and <), as well as those for “greater than or equal to” and “less than or equal to” (≥ and ≤). Those lists also advise against using @ and &, as people can mistake them for the numeral 2. Likewise, the plus sign should not be used, because it can look like the numeral 4. When in doubt, spell it out. Here are a few symbols that medical assistants might still see in handwritten medical records. These can also be risky: ↑ could look like the numeral 7, ↓ could look like the numeral 1, and º could look like the numeral 0. SYMBOL MEANING # Pounds, number ↑ Increase ©2023 Assessment Technologies Institute, L.L.C 7  Foundational Knowledge and Basic Science: Medical Terminology SYMBOL MEANING ↓ Decrease ♂ Male ♀ Female ‘ Feet “ Inches ° Degrees Medical Word Building As familiarity with medical terminology grows, it becomes easy to notice similarities among these terms. That is because many of them share common roots, prefixes, and suffixes. Putting together these components builds many medical terms. However, it doesn’t work to just mix and match three components and find a word that is in universal use. For example, hemi- means half, narc means sleep, and -ism means condition. But a patient chronically getting half the amount of sleep they should get isn’t heminarcism. There is no such word. Also, with some combinations, the result requires interpretation, because the literal meaning might vary a little from the actual meaning. An example is antibiotic, a combination of the prefix anti-, meaning against, and the word root bio, meaning life. Antibiotics are not incompatible with life. They kill a particular type of living organism: bacteria. Also, not all medical terms adhere to the prefix-root-suffix schema. However, looking at a word that has any one of those word components in it can offer a clue to what the term means. Word Roots Word roots are the core component of many words. Medical terms usually have one root but can have two or more. For example, hem- means blood, and -rrhage means excessive flow. The “o” between the two creates the medical term hemorrhage, meaning excessive blood flow. Not all word roots relate to a body system or a body part, but the following tables lists some of the terms that do. Common Word Roots ©2023 Assessment Technologies Institute, L.L.C 8  Foundational Knowledge and Basic Science: Medical Terminology Endocrine WORD ROOT MEANING Aden Gland Pancreat Pancreas Thyr Thyroid gland Hematologic WORD ROOT MEANING Hem, hemat Blood Phleb Vein Thromb Clot Musculoskeletal WORD ROOT MEANING Arthr Joint Brachi Arm Cervic Neck Chondr Cartilage Cost Rib Crani Skull Dactyl Finger or toe Fibr Connective tissue ©2023 Assessment Technologies Institute, L.L.C 9  Foundational Knowledge and Basic Science: Medical Terminology WORD ROOT MEANING My Muscle Oste Bone Pod Foot Sacr Sacrum Spondyl, vertebr Vertebra Ten, tendin Tendon Gastrointestinal WORD ROOT MEANING Abdomin Abdomen An Anus Appendic Appendix Bil, chol Bile, gall Col Colon Dent Teeth Enter Intestines Esophag Esophagus Gastr Stomach Gingiv Gums Gloss Tongue Hepat Liver ©2023 Assessment Technologies Institute, L.L.C 10  Foundational Knowledge and Basic Science: Medical Terminology WORD ROOT MEANING Icter Jaundice Ile Ileum Lapar Abdominal wall Lingu Tongue Pancreat Pancreas Pepsia Digestion Phag Eating, swallowing Proct Rectum Splen Spleen Stomat Mouth Genitourinary/Reproductive WORD ROOT MEANING Andr Male Colp Vagina Cyst Bladder Gravid Pregnant Gynec Female Hyster Uterus Mamm, mast Breast Metr Uterus ©2023 Assessment Technologies Institute, L.L.C 11  Foundational Knowledge and Basic Science: Medical Terminology WORD ROOT MEANING Nephr Kidney Ov Ovum Oophor Ovary Orchid Testicles Prostat Prostate gland Pyel Pelvis of the kidney Ren Renal/kidney Salping Fallopian tube Ureter Ureters Ur Urinary Vesic Bladder Respiratory WORD ROOT MEANING Bronch Bronchial Laryng Larynx Nas Nose Pleur Pleura Pneum, pneumon Lungs, air Pulmon Lung Rhin Nose ©2023 Assessment Technologies Institute, L.L.C 12  Foundational Knowledge and Basic Science: Medical Terminology WORD ROOT MEANING Steth Chest Thorac Thorax Trache Trachea Integumentary WORD ROOT MEANING Derm, dermat Skin Hidr Sweat Trich Hair Onych Nail Xer Dry Cardiovascular WORD ROOT MEANING Angi Blood vessel Arteri, arter Artery Cardi Heart Vas Vessel Ven Vein ©2023 Assessment Technologies Institute, L.L.C 13  Foundational Knowledge and Basic Science: Medical Terminology Neurologic WORD ROOT MEANING Blephar Eyelid Cephal Head Cerebr Cerebrum Encephal Brain Esthesi Sensation Irid, ird Iris Mening, meningi Membranes, meninges Myel Spinal cord, bone marrow Myring Eardrum Neur Nerve Ocul, ophthalm Eye Ot Ear Other WORD ROOT MEANING Adip Fat Bio Life Carcin Cancer Cry Cold Dors Back portion of the body ©2023 Assessment Technologies Institute, L.L.C 14  Foundational Knowledge and Basic Science: Medical Terminology WORD ROOT MEANING Gluc, glyc Sugar Hemi Hernia Hist Tissue Hydra Water Lact Milk Later Side Lip Fat Lith Stone Med, medi Middle Narc Numbness, stupor, sleep Necr Death Onc Tumor Path Disease Ped Child; foot Psych Mind Pyo Pus Pyr Fever, heat Septic Infection Therm Heat Combining Root Words ©2023 Assessment Technologies Institute, L.L.C 15  Foundational Knowledge and Basic Science: Medical Terminology A combining form is a word root with a combining vowel. Often, the combining vowel makes the medical term easier to pronounce. In most cases, the combining vowel is an “o,” but it is sometimes “i” or “e.” A combining form should be used when the last word root in a medical term connects with a suffix that begins with a consonant. When the word root connects with a suffix that starts with a vowel, just the word root should be used. Combining Form Examples COMBINING WORD ROOT COMBINING VOWEL FORM SUFFIX MEDICAL TERM Col O Col/o -stomy Colostomy Cephal O Cephal/o -algia Cephalagia Col O Col/o -ectomy Colectomy Cephal O Cephal/o -dynia Cephalodynia When the suffix begins with a vowel, the word root is used. Examples include cephalalgia and colectomy. However, when the suffix begins with a consonant, the combining form is used, as in colostomy and cephalodynia. When connecting two word roots, always use the connecting vowel, even if the following word root begins with a vowel. Prefixes Prefixes are word components that appear at the beginning of a word to change the meaning of the rest of the word. They generally mean the same thing in each word they modify. Some medical terms have no prefix. An example is splenectomy, a combination of the word root splen, meaning spleen, and the suffix -ectomy, meaning removal. The following is a list of some of the common prefixes medical assistants will encounter. Common Prefixes PREFIX MEANING PREFIX MEANING A-, an- Without Mega- Exceptionally large Ab- Away, from Meso- Middle ©2023 Assessment Technologies Institute, L.L.C 16  Foundational Knowledge and Basic Science: Medical Terminology PREFIX MEANING PREFIX MEANING Ad- Toward Meta- Over, beyond Ambi- Both Micro- Small Ante- Before Mono- One Anti- Against Multi- Many Auto- Self Neo- New Bi- Two, twice, double Nulli- None Brady- Slow Peri- Around Circum- Around Poly- Many Contra- Against Post- After, behind De- Down Pre-, pro- Before, in front of Dys- Painful, abnormal, Presby- Older age difficult, bad Endo- Within, inside Primi- First Epi- Above, on Pseudo- Eu- Normal, good Quadri- Four Ex-, extra-, Outside of Retro- Behind, in back of exo- Hemi- Half Sten- Narrowed Hyper- Above, excessive, Sub- Under increased Hypo- Below, decreased, Super-, supra- Above, excess insufficient Infra- Beneath Sym-, syn- Together, with ©2023 Assessment Technologies Institute, L.L.C 17  Foundational Knowledge and Basic Science: Medical Terminology PREFIX MEANING PREFIX MEANING Inter- Between, among Tachy- Fast Intra- Within, during Trans- Across Levo- To the left Tri- Three Macro- Large Ultra- Beyond, excess Mal- Bad Uni- One Suffixes Suffixes are word components that appear at the end of the word to change the meaning of the rest of the word. Some medical terms have no suffix, such as appendix. Some medical terms combine a prefix and a suffix with no word root. An example is hemiplegia, a combination of the prefix hemi-, meaning half, and the suffix -plegia, meaning paralysis. The following tables list some of the common general suffixes medical assistants will encounter, as well as some that are more specific to clinical disorders and medical, surgical, and diagnostic procedures. Common Suffixes General SUFFIX MEANING -age Related to -cidal, -cide Pertaining to killing -form Shape -fuge Driving away -iatry, -iatrist Healing by a provider/healer -ical Pertaining to -ion Process ©2023 Assessment Technologies Institute, L.L.C 18  Foundational Knowledge and Basic Science: Medical Terminology SUFFIX MEANING -logy, logist Study of, one who studies -ole Little, small -opia Vision -phylaxis Protection, prevention -pnea Breathing -therapy Treatment -uria Urine Surgery/Procedures SUFFIX MEANING -centesis Surgical puncture -cise Cut, remove -clasis Break down -desis Stabilization, binding -ectomy Removal, excision -gram Record -graph Instrument for recording -graphy Process of recording -ion Process -lepsy Seizure, convulsion -lysis Destruction, separation ©2023 Assessment Technologies Institute, L.L.C 19  Foundational Knowledge and Basic Science: Medical Terminology SUFFIX MEANING -meter Device for measuring -metry Process of measuring -pexy Fixation, to put in place -plasty Surgical repair, reformation -scopy Visual examination -spasm Involuntary twitch -stasis Stopping or controlling -stomy A new opening -tomy Incision -tripsy Crushing Disorders/conditions SUFFIX MEANING -algia Pain -asthenia Weakness -cele Swelling, herniation -dynia Pain -ectasis Dilation, expansion -emesis Vomiting -emia Blood condition -gen Producing ©2023 Assessment Technologies Institute, L.L.C 20  Foundational Knowledge and Basic Science: Medical Terminology SUFFIX MEANING -ia, -ism Condition of -iasis Presence of, formation of -I Inflammation -malacia Weakening or softening of -mania Obsessive preoccupation -megaly Enlargement -oid Seeming like -ole Small -oma Tumor -osis Condition, usually abnormal -pathy Disorder, disease -penia Deficiency, decrease -phagia Eating, swallowing -phasia Speech -phobia Fear -plasia Formation of -plegia Paralysis -ptosis Drooping, falling -rrhage Bursting forth -rrhea Flow, discharge -rrhexis Rupture ©2023 Assessment Technologies Institute, L.L.C 21  Foundational Knowledge and Basic Science: Medical Terminology SUFFIX MEANING -sclerosis Hardening condition -trophy Development Common Terms Usually, it is best to use lay terms instead of medical terminology when communicating with patients to ensure patients understand. Develop a knowledge base of lay terms associated with medical terms to effectively communicate with patients. ©2023 Assessment Technologies Institute, L.L.C 22  Foundational Knowledge and Basic Science: Medical Terminology Medical Terms MEDICAL TERM LAY LANGUAGE Hypertension High blood pressure Angina Chest pain Acute New, urgent, sudden Chronic Ongoing Alopecia Hair loss Cerebrovascular accident Stroke (CVA) Myocardial infarction Heart attack Edema Swelling CT scan CAT scan Cryotherapy Freezing off Abdomen Stomach Tachycardia Fast heart rate, heart beating fast, heart racing Bradycardia Low heart rate, heart beating slow Hyperglycemia High blood sugar Hypoglycemia Low blood sugar GERD Heartburn Shortness of breath Trouble breathing Phalanges Fingers and toes Arrhythmia Irregular heart rhythm ©2023 Assessment Technologies Institute, L.L.C 23  Foundational Knowledge and Basic Science: Medical Terminology MEDICAL TERM LAY LANGUAGE Erythrocytes Red blood cells Vertigo Dizziness, room spinning, dizzy, lightheaded Syncope Fainting, temporary loss of consciousness Deep vein thrombosis (DVT) Blood clot Osteoarthritis Wear and tear Amyotrophic lateral sclerosis Lou Gehrig’s disease (ALS) Positional and Directional Terminology Knowledge of the medical terms that indicate directions and positions is essential for communicating in health care. For example, for various types of examinations and diagnostic procedures, not only must patients be positioned correctly or optimally, those positions and how the patient tolerated them must also be documented. The following are lists of words medical assistants can use to help understand directional terms, as well as a list of terms that are essential for positioning. TERM DEFINITION Anatomical position Standard frame of reference in which the body is standing up, face forward, arms at the sides, palms forward, and toes pointed forward Supine Lying face up Prone Lying face down Dorsal recumbent Lying facing upward with flexed knees, feet flat on floor Fowler position Sitting upright with back angled at 90 degrees Semi-Fowler’s position Sitting with back angled at 45 degrees ©2023 Assessment Technologies Institute, L.L.C 24  Foundational Knowledge and Basic Science: Medical Terminology TERM DEFINITION Anterior Toward the front of the body, also known as ventral. Posterior Toward the back of the body, also known as dorsal. Superior Above; toward the head Inferior Below; toward the feet Medial Closer to the midline of the body Lateral Further from the midline of the body (toward the side) Superficial Closer to the surface of the body; more external Deep Farther from the body’s surface; more internal Proximal Closer to the body’s trunk Distal Further from the body’s trunk Dextrad Toward the right Sinistrad Toward the left ©2023 Assessment Technologies Institute, L.L.C 25  Foundational Knowledge and Basic Science: Health Care Systems and Settings Health Care Systems and Settings The medical field can seem overwhelming. New terminology, legal concerns, direct or indirect patient care, unique processes, and high expectations can contribute to initial apprehension. However, this new role can be better understood through a holistic approach, looking at the health care system from all sides. In addition to understanding the role and scope of practice, it is crucial to understand the importance of the entire health care team. Knowing the skills and responsibilities of the various allied health and specialty providers strengthens the effectiveness and cohesiveness of the health care team. Each team member needs to respect and assist others in providing the best possible care for the patient. Medical Assistant Roles, Responsibilities, Scope of Practice, and Titles MA Roles The role of an MA is primarily to work alongside a provider in an outpatient or ambulatory health care setting, such as a medical office. The MA can be cross-trained to perform both administrative and clinical duties. Administrative duties include greeting patients, scheduling, handling correspondence, and answering telephones. In addition, the MA is often responsible for obtaining medical histories from patients, providing patient education, performing laboratory tests, and preparing and administering immunizations. An MA achieves credentialing by passing a national certification exam. MA Responsibilities The responsibilities of an MA vary based on the setting in which they work. Duties can be primarily administrative, clinical, or a combination. Administrative Duties Scheduling patient appointments Patient registration (demographics, payer information, compliance forms) Updating and working in patient records Sending claims to insurance Collecting patient responsibility amounts (copays, coinsurance, deductible) ©2023 Assessment Technologies Institute, L.L.C 1  Foundational Knowledge and Basic Science: Health Care Systems and Settings Clinical Duties Collecting and processing lab specimens Performing diagnostic testing (EKG, spirometry) Preparing and cleaning examination rooms Preparing the patient for evaluation and procedure Measuring vital signs Preparing medications and administering immunizations The medical assistant’s role is constantly changing and evolving. In addition to traditional responsibilities, medical assistants are doing more patient navigation and care coordination work. In this role, medical assistants can guide patients as they journey through the health care system—helping them understand what is happening and what steps they need to take and helping them connect to the right specialists. To effectively support the patient in this way, the MA will often need to coordinate with other members of the patient care team, both within the clinic and externally with specialty care teams. The MA may ask questions on the patient’s behalf to nurses and providers within the team to better understand the plan of care and provide the information to the patient in a clear, easily understood way. When coordinating with other teams, medical assistants can provide helpful context about the patient’s social determinants of health and barriers to care, as well as support the patient in being scheduled appropriately and in a timely manner with specialists. Scope of Practice Scope of practice describes the duties delegated based on education, training, and experience. The scope of practice for the MA does not include the practice of medicine. Medical assistants should not perform duties they have not been trained or certified to do. Prior to practice, review the duties and restrictions related to medical assisting, which vary by state. Health care organizations may have stricter policies and procedures that they enforce, but they must comply with state regulations at minimum. Variables for the Scope of Practice Variables that affect the scope of practice for medical assistants include the regulations and policies issued by state medical boards. An MA with appropriate training may safely provide supportive services that are simple, routine medical tasks under the supervision of a licensed physician. In addition, the MA may only provide supportive services set forth by the medical office’s organizational policies. These often include measuring height and weight, measuring vital signs, and performing various diagnostic and ©2023 Assessment Technologies Institute, L.L.C 2  Foundational Knowledge and Basic Science: Health Care Systems and Settings laboratory testing. Organizational policies must adhere to state and government guidelines to comply with current laws. Titles Over 50 years ago, medical providers began hiring assistants to support their medical practice. They recognized the need for administrative support. Over time, this turned into the MA role, combining administrative and clinical responsibilities. In 1956, a formal medical assistant association was formed and recognized by 15 states. The profession continued to evolve and was recognized by the U.S. Department of Education in 1978. At that time, training was completed on the job by the provider and other office staff. This eventually became time-consuming and expensive for providers, at which point formalized training and certification programs arose. Many clinical offices look to hire only those who have completed formal training and certification, ensuring they have the necessary skill set to work in patient care. Offices also follow specific guidelines requiring medical assistants to have current certification to input data regarding government insurance reimbursements into electronic health records. Additional Certifications Medical assistants can further their careers and extend their scope of work through continued education, leading to additional certifications, including the following. Certified medical administrative assistant (CMAA) Certified phlebotomy technician (CPT) Certified EKG technician (CET) Certified billing and coding specialist (CBCS) Certified electronic health records specialist (CEHRS) Provider and Allied Health Roles, Responsibilities, Scope of Practice, Titles, and Credentials Physician Information When most people think of health care providers, they think of physicians, also known as doctors. All practicing doctors must be licensed in the state where they practice. To pursue a license, they must first complete eight years of school—four years of undergraduate college, followed by four years of medical or osteopathic school. Upon graduation, prospective physicians then move on to residency. Residency is a two- to seven-year training period where they receive intensive on-the-job training with the direct oversight of a licensed physician. Finally, physicians must pass parts I, II, and III of ©2023 Assessment Technologies Institute, L.L.C 3  Foundational Knowledge and Basic Science: Health Care Systems and Settings the U.S. Medical Licensing Examination. There are two primary types of physicians: medical doctor (MD) and doctor of osteopathy (DO). Their scope of practice and responsibilities are nearly the same, though their training and expertise have slight variations. Medical doctors are allopathic providers and the most widely recognized type of doctor. They diagnose illnesses, provide treatments, perform procedures such as surgical interventions, and write prescriptions. Doctors of osteopathy complete requirements like those of MDs to graduate and practice medicine. In addition to modern medicine and surgical procedures, DOs use osteopathic manipulative therapy to treat patients. In addition to physicians, there are two primary types of midlevel providers: physician assistants and nurse practitioners. Physician Assistant Physician assistants (PA) must practice medicine under the direction and supervision of a licensed MD or DO, but they can make clinical decisions. In order to be licensed as a PA in the state of practice, individuals must first complete at least four years of college, followed by two years of PA school. Most PAs will focus on a specific specialty, such as cardiology or orthopedics. Nurse Practitioner Nurse practitioners (NP) provide basic patient care services, including diagnosing and prescribing medications for common illnesses. Nurse practitioners require advanced academic training beyond the registered nurse (RN) degree and have an extensive amount of clinical experience. In most states, NPs must work under the supervision of a physician, but in some states they can practice independently. Nurses Nurses are found in almost every health care setting. A licensed practical nurse (LPN) must be licensed in their state. Typically, one year of schooling through an accredited program, along with passing a state board examination, is required to obtain an LPN license. LPNs are somewhat limited in their scope of practice, as the role is designed to be assistive. They can measure vital signs, administer some medications, and perform clinical care such as wound care. Often, the role of an LPN is to observe patients, recording and reporting on status changes. While they may work in many different settings, a primary use of LPNs recently is in long-term care settings due to the increasing number of older adults in the general population.In some states, and LPN may also be referred to as an LVN (licensed vocational nurse). ©2023 Assessment Technologies Institute, L.L.C 4  Foundational Knowledge and Basic Science: Health Care Systems and Settings A registered nurse (RN) must complete more schooling in the form of an associate degree, diploma graduate, or baccalaureate degree. They, too, must pass a state board examination to be licensed. Due to the more intensive training, RNs have a much broader scope of practice than LPNs. RNs can work in clinical settings, public health agencies, administrative capacities, and educational settings. Allied Health Professionals Medical laboratory technicians perform diagnostic testing on blood, bodily fluids, and other specimens under the supervision of a medical technologist. Medical receptionists check patients in and out, answer phones, schedule appointments, and perform other administrative tasks. Occupational therapists assist patients who have conditions that disable them developmentally, emotionally, mentally, or physically. Pharmacy technicians may perform routine medication dispensing functions that do not require the expertise or judgment of a licensed pharmacist. Pharmacy technicians must work under the direct supervision of a pharmacist. Physical therapists assist patients in improving mobility, strength, and range of motion. Radiology technicians use various imaging equipment to assist the provider in diagnosing and treating certain diseases. Licensing Versus Certification and Maintenance of Certification Licensure vs. Certification A medical school graduate must be licensed before beginning the practice of medicine. Being licensed by the state to practice medicine allows them to diagnose conditions and provide treatment. Licensing helps ensure that anyone providing medical care has the adequate knowledge and skill set to do so safely. It is important to understand the laws and regulations within each state to avoid violations of any kind. Health Care Licensure Licensure is regulated by state statutes through the medical practice acts. An MD, DO, or Doctor of Chiropractic degree is issued upon graduation from a medical or chiropractic institute. Licensure for physicians is mandatory and controlled by a state board of medical examiners. Licensure may be accomplished by examination, reciprocity, or endorsement. Every state requires a written examination for MDs to practice. Some ©2023 Assessment Technologies Institute, L.L.C 5  Foundational Knowledge and Basic Science: Health Care Systems and Settings states grant the license to practice medicine by reciprocity, which automatically recognizes that the requirements were met by another state. Graduates of medical schools in the U.S. are licensed by the endorsement of the national board certification. Licensure by endorsement is granted on a case-by-case basis based on examinations. Graduates not licensed by endorsement must pass the state board exam. As of 2022, no state requires medical assistants to be licensed. However, some states dictate that to complete specific services such as x-rays, individuals must have a license to perform that particular skill. For example, Florida does not require a medical assistant to have a license to collect prescribed routine laboratory specimens. However, in Washington, even nationally certified medical assistants must get licensing credentials through the Washington State Department of Health to perform phlebotomy or EKGs. Certification In addition, the government may require certification for the medical assistant to enter prescriptions into a computerized order-entry system. Advantages of certification include increased initial job placement, higher wages, and career advancement opportunities. Maintaining a Certification Once certification is obtained, it must be maintained to stay current. This ensures that medical assistants have the most up-to-date information about the medical field and provides validity to the overall profession. Each certification has different requirements for recertification, so medical assistants should understand and follow the recertification process of the organization sponsoring their certification. Types of Health Care Organizations and Delivery Models Inpatient and Outpatient Inpatient care occurs while the patient is admitted to a hospital or facility. Ambulatory care refers to any care received in an outpatient facility. This includes many types of care settings. Primary Care Clinics Primary care clinics are outpatient care settings where patients are seen for routine type visits, including wellness checks, prevention counseling, chronic conditions, medication management, and minor acute needs. Primary care will be discussed in more detail later in the chapter. Specialty Care Clinics ©2023 Assessment Technologies Institute, L.L.C 6  Foundational Knowledge and Basic Science: Health Care Systems and Settings Specialty care clinics are outpatient facilities where patients who have complex or severe diseases and conditions are seen for routine visits by doctors who specialize in a specific disease or condition. Home Health Home health refers to specific types of care provided to those who cannot leave their home easily. Physical, occupational, and speech therapy are common types of home care. Skilled nursing is also common in the home health setting. It must be prescribed and overseen by a provider, typically a primary care provider (PCP). Home health is not used on an ongoing basis for a patient but is ordered for a set period based on an acute event, usually hospitalization. Home health orders include goals for the patient, such as managing their medications and ambulating safely. The service is complete when the goals are reached. Medical assistants working for the ordering provider are often responsible for submitting the order for home health, coordinating to ensure the patient is enrolled and scheduled, and assisting with the administrative aspects of the orders. Mobile Health Units Mobile health units bring health care to the communities that most need it and may otherwise lack access to the services provided. Teams working in a mobile health unit are equipped with means of transportation that allow for the setup and use of specialized medical equipment. There are mobile health units in the U.S. While this concept has been in use for services such as mobile stroke units, mobile urgent cares, and mobile mammogram buses, the COVID-19 pandemic brought this type of care to much of the country in the form of mobile testing and vaccination options. Hospice Hospice care is end-of-life care focused on comfort rather than curative efforts. Patients can qualify for hospice care if they have a terminal illness at the end stage. It can be delivered as outpatient or inpatient care. Typically, a patient will begin hospice outpatient but can transition to inpatient care as they need a higher level of care near the end of life. Patient-Centered Medical Home The patient-centered medical home (PCMH) is a care delivery model in which a PCP coordinates treatment to ensure patients receive the required care when and where they need it and in a way they can understand. This encompasses all aspects of care, from prevention and wellness education to acute illness and chronic disease management to end-of-life care. The PCMH is a team-based approach to health care in which a provider leads an interprofessional team to work collaboratively and effectively for their patients. Medical assistants are an integral piece of the PCMH team—assisting ©2023 Assessment Technologies Institute, L.L.C 7  Foundational Knowledge and Basic Science: Health Care Systems and Settings with direct patient care, care coordination, patient education, and administrative tasks essential to the model. Technology-Based Methods for Providing Health Care and Information Telehealth and Virtual Visits Telehealth is health care delivered virtually, most commonly via video call. The increase in telehealth expanded to eliminate patients from coming in contact with communicable diseases, provide convenience, and allow patients in rural areas to obtain specialty care where it may not have been offered before. Telehealth can be an excellent option for patients and providers to review many aspects of care, but it does come with limitations. Medical assistants may have multiple responsibilities when it comes to virtual visits. Scheduling virtual visits may require more time because the MA must gather or confirm the patient’s email address, ensure the link has been sent, and review instructions. Some offices offer patients a test visit in which an administrator or MA will log into the link to ensure the patient can access it when it is time for their appointment. Medical assistants may also participate in the actual visit, just as they would with a standard office visit. This can include gathering a history, verifying medication and pharmacy information, setting an agenda, and following up with the patient on the next steps, such as referral or diagnostic testing coordination. Patient Portals Patient portals are a common feature in electric health records. This feature allows patients to log into a patient-facing aspect of the EHR to view their personal health information, such as test results, visit notes, and patient education materials. Many patient portals include an option to securely message the health care team about concerns and plans of care. Some portals also allow patients to schedule appointments directly without needing to call the office. The benefits of patient portals include increased transparency about care, decreased wait times for patients to receive results, and reduced demand on the office staff due to direct access limiting the need for phone calls. The MA may be responsible for uploading information to the portal, as well as assisting the patient with enrolling and getting set up with an account. Medical assistants should understand the portal’s functionality and the clinic’s policies and procedures around appropriate use. ©2023 Assessment Technologies Institute, L.L.C 8  Foundational Knowledge and Basic Science: Health Care Systems and Settings Health Care Payment Models Fee for Service The U.S. health care system is largely based on the fee-for-service model in which providers and medical facilities bill insurance and patients for the services provided. Every examination, medical service, test, and procedure has an associated procedural code and charge. These charges are managed through the provider’s medical billing department and sent to the insurance (or directly to the patient) for payment. The insurance then charges the patient a predetermined amount for which they are responsible. Value-Based Plans The health care system is increasingly moving toward value-based plans or care. The goals of value-based care are summarized in the Quadruple Aim. Improved patient outcomes Improved patient satisfaction Lower cost Health care professional well-being Rather than costs being determined by each service, the cost is more holistic. This model prioritizes prevention and early intervention over complex intervention to prevent unnecessary downstream costs. Clinics and health care systems that adopt this model are rewarded financially for keeping patients healthy rather than making money based on visits, procedures, and interventions once the patient has become ill. Other Health Care Models MODEL DESCRIPTION Managed care An umbrella term for plans that provide health care in return for preset scheduled payments and coordinated care through a defined network of providers and hospitals. Capitation (partial or Patients are assigned a per-member, per-month payment based on full) age, race, sex, lifestyle, medical history, and benefit design. Payment rates are tied to expected usage regardless of how often the patient visits. Like bundled payment models, providers are incentivized to help patients avoid high-cost procedures and tests to maximize their compensation. Under partial- or blended-capitation models, only specific types or categories of services are paid based on capitation. ©2023 Assessment Technologies Institute, L.L.C 9  Foundational Knowledge and Basic Science: Health Care Systems and Settings MODEL DESCRIPTION Health maintenance This plan contracts with a medical center or group of providers to organization (HMO) provide preventive and acute care for the insured person. HMOs generally require referrals to specialists, as well as precertification and preauthorization for hospital admissions, outpatient procedures, and treatments. Preferred provider These plans have more flexibility than HMO plans. An insured person organization (PPO) does not need a PCP and can go directly to a specialist without referrals. Although patients can see providers in or out of their network, an in-network provider usually costs less. Point-of-service (POS) POS plans allow a great deal of flexibility for patients. They can self- plan refer to specialists and do not need an assigned PCP. Like PPO, the cost depends on whether the providers they see are within the plan’s panel. General vs. Specialty Health Care and Services General Health Care Services General practitioners (GPs) are medical doctors who treat acute and chronic illnesses and provide patients with preventive care and health education. A GP may take a holistic approach to general practice that considers the biological, psychological, and social aspects relevant to the care of each patient’s illness. Family practitioners offer care to the whole family, from newborns to older adults. They are familiar with a range of disorders and diseases. However, preventive care is their primary concern. Internists provide comprehensive care for adults, often diagnosing and treating chronic, long-term conditions. They also offer treatment for common illnesses and preventive care. Internists must have a broad understanding of the body and its ailments to diagnose conditions and provide treatment. Internists may focus on pediatric or adult medicine rather than provide care across the lifespan. Specialty Health Care Services Specialist care is used when a disease or diagnosis escalates beyond the area of expertise of a PCP. Specialists are providers focused on diagnosing and treating diseases and disorders of specific body systems. Specialist Care ©2023 Assessment Technologies Institute, L.L.C 10  Foundational Knowledge and Basic Science: Health Care Systems and Settings SPECIALIST FOCUS Allergist Evaluates disorders and diseases of the immune system, including adverse reactions to medications and food, anaphylaxis, problems related to autoimmune disease, and asthma Anesthesiologist Manages pain or administers sedation medications during surgical procedures Cardiologist Diagnoses and treats diseases or conditions of the heart and blood vessels Dermatologist Diagnoses and treats skin conditions Endocrinologist Diagnoses and treats hormonal and glandular conditions; often works with patients who have diabetes Gastroenterologist Manages diseases of the GI tract (stomach, intestines, esophagus, liver, pancreas, colon, and rectum) Gynecologist Diagnoses and treats internal reproductive system and fertility disorders Hematologist Diagnoses and treats blood and blood-producing organs, patients who have anemia, leukemia, and lymphoma Hepatologists Studies and treats diseases related to the liver, biliary tree, gallbladder, and pancreas Neonatologist Provides care of newborns, specifically those who are ill or premature Nephrologist Manages diseases and disorders of the kidney and its associated structures Obstetrician Provides care of patients during and after pregnancy Oncologist Treats and provides care for patients who have cancer Ophthalmologist Diagnoses and treats diseases and conditions of the eye Orthopedist Treats injuries and diseases of the bones, joints, muscles, tendons, and ligaments Neurologist Treats diseases and disorders of the brain and nervous system Otolaryngologist Treats diseases and conditions of the ear, nose, and throat Pediatrician Manages newborn to adolescent health ©2023 Assessment Technologies Institute, L.L.C 11  Foundational Knowledge and Basic Science: Health Care Systems and Settings SPECIALIST FOCUS Psychiatrist Diagnoses and treats mental disorders and conditions Radiologist Uses and interprets imaging to detect abnormalities in the body Urologist Manages disorders of the urinary tract Ancillary Services and Complementary Therapies Ancillary Services Providing ancillary services in the provider’s office adds convenience for patients and increases revenue for the organization. Ancillary services meet a specific medical need for a particular population. Urgent care provides an alternative to the emergency department. They cost less, have a shorter wait time, and are often conveniently located. Most have flexible hours and offer walk-in appointments. They are appropriate to use for non-life-threatening acute injuries and illnesses. Laboratory services perform diagnostic testing on blood, body fluids, and other specimens to conclude a diagnosis for the provider. Diagnostic imaging machines such as x-ray equipment, ultrasound machines, magnetic resonance imaging (MRI), and computerized tomography (CT) take images of body parts to further diagnose a condition. Occupational therapy assists patients who have conditions that disable them developmentally, emotionally, mentally, or physically. Occupational therapy helps the patient compensate for the loss of functions and rebuild to a functional level. Physical therapy assists patients in regaining mobility and improving strength and range of motion, often impaired by an accident, injury, or disease. Complementary Therapies Acupuncture involves pricking the skin or tissues with needles to relieve pain and treat various physical, mental, and emotional conditions. Chiropractic medicine diagnoses and treats pain and overall body function through spinal manipulation and alignment. Energy therapy is the calm method of clearing cellular memory through the human energy field, promoting health, balance, and relaxation. It centers on the connection ©2023 Assessment Technologies Institute, L.L.C 12  Foundational Knowledge and Basic Science: Health Care Systems and Settings between life’s physical, emotional, and mental states found in various holistic healing techniques. Dietary supplements contain one or more dietary ingredients, including vitamins, minerals, herbs, or other botanicals. A plant or part of a plant (flowers, leaves, bark, fruit, seeds, stems, roots, amino acids) is used for its flavor, scent, or potential therapeutic properties. ©2023 Assessment Technologies Institute, L.L.C 13  Foundational Knowledge and Basic Science: Health Care Systems and Settings Health Care Systems and Settings The medical field can seem overwhelming. New terminology, legal concerns, direct or indirect patient care, unique processes, and high expectations can contribute to initial apprehension. However, this new role can be better understood through a holistic approach, looking at the health care system from all sides. In addition to understanding the role and scope of practice, it is crucial to understand the importance of the entire health care team. Knowing the skills and responsibilities of the various allied health and specialty providers strengthens the effectiveness and cohesiveness of the health care team. Each team member needs to respect and assist others in providing the best possible care for the patient. Medical Assistant Roles, Responsibilities, Scope of Practice, and Titles MA Roles The role of an MA is primarily to work alongside a provider in an outpatient or ambulatory health care setting, such as a medical office. The MA can be cross-trained to perform both administrative and clinical duties. Administrative duties include greeting patients, scheduling, handling correspondence, and answering telephones. In addition, the MA is often responsible for obtaining medical histories from patients, providing patient education, performing laboratory tests, and preparing and administering immunizations. An MA achieves credentialing by passing a national certification exam. MA Responsibilities The responsibilities of an MA vary based on the setting in which they work. Duties can be primarily administrative, clinical, or a combination. Administrative Duties Scheduling patient appointments Patient registration (demographics, payer information, compliance forms) Updating and working in patient records Sending claims to insurance Collecting patient responsibility amounts (copays, coinsurance, deductible) ©2023 Assessment Technologies Institute, L.L.C 1  Foundational Knowledge and Basic Science: Health Care Systems and Settings Clinical Duties Collecting and processing lab specimens Performing diagnostic testing (EKG, spirometry) Preparing and cleaning examination rooms Preparing the patient for evaluation and procedure Measuring vital signs Preparing medications and administering immunizations The medical assistant’s role is constantly changing and evolving. In addition to traditional responsibilities, medical assistants are doing more patient navigation and care coordination work. In this role, medical assistants can guide patients as they journey through the health care system—helping them understand what is happening and what steps they need to take and helping them connect to the right specialists. To effectively support the patient in this way, the MA will often need to coordinate with other members of the patient care team, both within the clinic and externally with specialty care teams. The MA may ask questions on the patient’s behalf to nurses and providers within the team to better understand the plan of care and provide the information to the patient in a clear, easily understood way. When coordinating with other teams, medical assistants can provide helpful context about the patient’s social determinants of health and barriers to care, as well as support the patient in being scheduled appropriately and in a timely manner with specialists. Scope of Practice Scope of practice describes the duties delegated based on education, training, and experience. The scope of practice for the MA does not include the practice of medicine. Medical assistants should not perform duties they have not been trained or certified to do. Prior to practice, review the duties and restrictions related to medical assisting, which vary by state. Health care organizations may have stricter policies and procedures that they enforce, but they must comply with state regulations at minimum. Variables for the Scope of Practice Variables that affect the scope of practice for medical assistants include the regulations and policies issued by state medical boards. An MA with appropriate training may safely provide supportive services that are simple, routine medical tasks under the supervision of a licensed physician. In addition, the MA may only provide supportive services set forth by the medical office’s organizational policies. These often include measuring height and weight, measuring vital signs, and performing various diagnostic and ©2023 Assessment Technologies Institute, L.L.C 2  Foundational Knowledge and Basic Science: Health Care Systems and Settings laboratory testing. Organizational policies must adhere to state and government guidelines to comply with current laws. Titles Over 50 years ago, medical providers began hiring assistants to support their medical practice. They recognized the need for administrative support. Over time, this turned into the MA role, combining administrative and clinical responsibilities. In 1956, a formal medical assistant association was formed and recognized by 15 states. The profession continued to evolve and was recognized by the U.S. Department of Education in 1978. At that time, training was completed on the job by the provider and other office staff. This eventually became time-consuming and expensive for providers, at which point formalized training and certification programs arose. Many clinical offices look to hire only those who have completed formal training and certification, ensuring they have the necessary skill set to work in patient care. Offices also follow specific guidelines requiring medical assistants to have current certification to input data regarding government insurance reimbursements into electronic health records. Additional Certifications Medical assistants can further their careers and extend their scope of work through continued education, leading to additional certifications, including the following. Certified medical administrative assistant (CMAA) Certified phlebotomy technician (CPT) Certified EKG technician (CET) Certified billing and coding specialist (CBCS) Certified electronic health records specialist (CEHRS) Provider and Allied Health Roles, Responsibilities, Scope of Practice, Titles, and Credentials Physician Information When most people think of health care providers, they think of physicians, also known as doctors. All practicing doctors must be licensed in the state where they practice. To pursue a license, they must first complete eight years of school—four years of undergraduate college, followed by four years of medical or osteopathic school. Upon graduation, prospective physicians then move on to residency. Residency is a two- to seven-year training period where they receive intensive on-the-job training with the direct oversight of a licensed physician. Finally, physicians must pass parts I, II, and III of ©2023 Assessment Technologies Institute, L.L.C 3  Foundational Knowledge and Basic Science: Health Care Systems and Settings the U.S. Medical Licensing Examination. There are two primary types of physicians: medical doctor (MD) and doctor of osteopathy (DO). Their scope of practice and responsibilities are nearly the same, though their training and expertise have slight variations. Medical doctors are allopathic providers and the most widely recognized type of doctor. They diagnose illnesses, provide treatments, perform procedures such as surgical interventions, and write prescriptions. Doctors of osteopathy complete requirements like those of MDs to graduate and practice medicine. In addition to modern medicine and surgical procedures, DOs use osteopathic manipulative therapy to treat patients. In addition to physicians, there are two primary types of midlevel providers: physician assistants and nurse practitioners. Physician Assistant Physician assistants (PA) must practice medicine under the direction and supervision of a licensed MD or DO, but they can make clinical decisions. In order to be licensed as a PA in the state of practice, individuals must first complete at least four years of college, followed by two years of PA school. Most PAs will focus on a specific specialty, such as cardiology or orthopedics. Nurse Practitioner Nurse practitioners (NP) provide basic patient care services, including diagnosing and prescribing medications for common illnesses. Nurse practitioners require advanced academic training beyond the registered nurse (RN) degree and have an extensive amount of clinical experience. In most states, NPs must work under the supervision of a physician, but in some states they can practice independently. Nurses Nurses are found in almost every health care setting. A licensed practical nurse (LPN) must be licensed in their state. Typically, one year of schooling through an accredited program, along with passing a state board examination, is required to obtain an LPN license. LPNs are somewhat limited in their scope of practice, as the role is designed to be assistive. They can measure vital signs, administer some medications, and perform clinical care such as wound care. Often, the role of an LPN is to observe patients, recording and reporting on status changes. While they may work in many different settings, a primary use of LPNs recently is in long-term care settings due to the increasing number of older adults in the general population.In some states, and LPN may also be referred to as an LVN (licensed vocational nurse). ©2023 Assessment Technologies Institute, L.L.C 4  Foundational Knowledge and Basic Science: Health Care Systems and Settings A registered nurse (RN) must complete more schooling in the form of an associate degree, diploma graduate, or baccalaureate degree. They, too, must pass a state board examination to be licensed. Due to the more intensive training, RNs have a much broader scope of practice than LPNs. RNs can work in clinical settings, public health agencies, administrative capacities, and educational settings. Allied Health Professionals Medical laboratory technicians perform diagnostic testing on blood, bodily fluids, and other specimens under the supervision of a medical technologist. Medical receptionists check patients in and out, answer phones, schedule appointments, and perform other administrative tasks. Occupational therapists assist patients who have conditions that disable them developmentally, emotionally, mentally, or physically. Pharmacy technicians may perform routine medication dispensing functions that do not require the expertise or judgment of a licensed pharmacist. Pharmacy technicians must work under the direct supervision of a pharmacist. Physical therapists assist patients in improving mobility, strength, and range of motion. Radiology technicians use various imaging equipment to assist the provider in diagnosing and treating certain diseases. Licensing Versus Certification and Maintenance of Certification Licensure vs. Certification A medical school graduate must be licensed before beginning the practice of medicine. Being licensed by the state to practice medicine allows them to diagnose conditions and provide treatment. Licensing helps ensure that anyone providing medical care has the adequate knowledge and skill set to do so safely. It is important to understand the laws and regulations within each state to avoid violations of any kind. Health Care Licensure Licensure is regulated by state statutes through the medical practice acts. An MD, DO, or Doctor of Chiropractic degree is issued upon graduation from a medical or chiropractic institute. Licensure for physicians is mandatory and controlled by a state board of medical examiners. Licensure may be accomplished by examination, reciprocity, or endorsement. Every state requires a written examination for MDs to practice. Some ©2023 Assessment Technologies Institute, L.L.C 5  Foundational Knowledge and Basic Science: Health Care Systems and Settings states grant the license to practice medicine by reciprocity, which automatically recognizes that the requirements were met by another state. Graduates of medical schools in the U.S. are licensed by the endorsement of the national board certification. Licensure by endorsement is granted on a case-by-case basis based on examinations. Graduates not licensed by endorsement must pass the state board exam. As of 2022, no state requires medical assistants to be licensed. However, some states dictate that to complete specific services such as x-rays, individuals must have a license to perform that particular skill. For example, Florida does not require a medical assistant to have a license to collect prescribed routine laboratory specimens. However, in Washington, even nationally certified medical assistants must get licensing credentials through the Washington State Department of Health to perform phlebotomy or EKGs. Certification In addition, the government may require certification for the medical assistant to enter prescriptions into a computerized order-entry system. Advantages of certification include increased initial job placement, higher wages, and career advancement opportunities. Maintaining a Certification Once certification is obtained, it must be maintained to stay current. This ensures that medical assistants have the most up-to-date information about the medical field and provides validity to the overall profession. Each certification has different requirements for recertification, so medical assistants should understand and follow the recertification process of the organization sponsoring their certification. Types of Health Care Organizations and Delivery Models Inpatient and Outpatient Inpatient care occurs while the patient is admitted to a hospital or facility. Ambulatory care refers to any care received in an outpatient facility. This includes many types of care settings. Primary Care Clinics Primary care clinics are outpatient care settings where patients are seen for routine type visits, including wellness checks, prevention counseling, chronic conditions, medication management, and minor acute needs. Primary care will be discussed in more detail later in the chapter. Specialty Care Clinics ©2023 Assessment Technologies Institute, L.L.C 6  Foundational Knowledge and Basic Science: Health Care Systems and Settings Specialty care clinics are outpatient facilities where patients who have complex or severe diseases and conditions are seen for routine visits by doctors who specialize in a specific disease or condition. Home Health Home health refers to specific types of care provided to those who cannot leave their home easily. Physical, occupational, and speech therapy are common types of home care. Skilled nursing is also common in the home health setting. It must be prescribed and overseen by a provider, typically a primary care provider (PCP). Home health is not used on an ongoing basis for a patient but is ordered for a set period based on an acute event, usually hospitalization. Home health orders include goals for the patient, such as managing their medications and ambulating safely. The service is complete when the goals are reached. Medical assistants working for the ordering provider are often responsible for submitting the order for home health, coordinating to ensure the patient is enrolled and scheduled, and assisting with the administrative aspects of the orders. Mobile Health Units Mobile health units bring health care to the communities that most need it and may otherwise lack access to the services provided. Teams working in a mobile health unit are equipped with means of transportation that allow for the setup and use of specialized medical equipment. There are mobile health units in the U.S. While this concept has been in use for services such as mobile stroke units, mobile urgent cares, and mobile mammogram buses, the COVID-19 pandemic brought this type of care to much of the country in the form of mobile testing and vaccination options. Hospice Hospice care is end-of-life care focused on comfort rather than curative efforts. Patients can qualify for hospice care if they have a terminal illness at the end stage. It can be delivered as outpatient or inpatient care. Typically, a patient will begin hospice outpatient but can transition to inpatient care as they need a higher level of care near the end of life. Patient-Centered Medical Home The patient-centered medical home (PCMH) is a care delivery model in which a PCP coordinates treatment to ensure patients receive the required care when and where they need it and in a way they can understand. This encompasses all aspects of care, from prevention and wellness education to acute illness and chronic disease management to end-of-life care. The PCMH is a team-based approach to health care in which a provider leads an interprofessional team to work collaboratively and effectively for their patients. Medical assistants are an integral piece of the PCMH team—assisting ©2023 Assessment Technologies Institute, L.L.C 7  Foundational Knowledge and Basic Science: Health Care Systems and Settings with direct patient care, care coordination, patient education, and administrative tasks essential to the model. Technology-Based Methods for Providing Health Care and Information Telehealth and Virtual Visits Telehealth is health care delivered virtually, most commonly via video call. The increase in telehealth expanded to eliminate patients from coming in contact with communicable diseases, provide convenience, and allow patients in rural areas to obtain specialty care where it may not have been offered before. Telehealth can be an excellent option for patients and providers to review many aspects of care, but it does come with limitations. Medical assistants may have multiple responsibilities when it comes to virtual visits. Scheduling virtual visits may require more time because the MA must gather or confirm the patient’s email address, ensure the link has been sent, and review instructions. Some offices offer patients a test visit in which an administrator or MA will log into the link to ensure the patient can access it when it is time for their appointment. Medical assistants may also participate in the actual visit, just as they would with a standard office visit. This can include gathering a history, verifying medication and pharmacy information, setting an agenda, and following up with the patient on the next steps, such as referral or diagnostic testing coordination. Patient Portals Patient portals are a common feature in electric health records. This feature allows patients to log into a patient-facing aspect of the EHR to view their personal health information, such as test results, visit notes, and patient education materials. Many patient portals include an option to securely message the health care team about concerns and plans of care. Some portals also allow patients to schedule appointments directly without needing to call the office. The benefits of patient portals include increased transparency about care, decreased wait times for patients to receive results, and reduced demand on the office staff due to direct access limiting the need for phone calls. The MA may be responsible for uploading information to the portal, as well as assisting the patient with enrolling and getting set up with an account. Medical assistants should understand the portal’s functionality and the clinic’s policies and procedures around appropriate use. ©2023 Assessment Technologies Institute, L.L.C 8  Foundational Knowledge and Basic Science: Health Care Systems and Settings Health Care Payment Models Fee for Service The U.S. health care system is largely based on the fee-for-service model in which providers and medical facilities bill insurance and patients for the services provided. Every examination, medical service, test, and procedure has an associated procedural code and charge. These charges are managed through the provider’s medical billing department and sent to the insurance (or directly to the patient) for payment. The insurance then charges the patient a predetermined amount for which they are responsible. Value-Based Plans The health care system is increasingly moving toward value-based plans or care. The goals of value-based care are summarized in the Quadruple Aim. Improved patient outcomes Improved patient satisfaction Lower cost Health care professional well-being Rather than costs being determined by each service, the cost is more holistic. This model prioritizes prevention and early intervention over complex intervention to prevent unnecessary downstream costs. Clinics and health care systems that adopt this model are rewarded financially for keeping patients healthy rather than making money based on visits, procedures, and interventions once the patient has become ill. Other Health Care Models MODEL DESCRIPTION Managed care An umbrella term for plans that provide health care in return for preset scheduled payments and coordinated care through a defined network of providers and hospitals. Capitation (partial or Patients are assigned a per-member, per-month payment based on full) age, race, sex, lifestyle, medical history, and benefit design. Payment rates are tied to expected usage regardless of how often the patient visits. Like bundled payment models, providers are incentivized to help patients avoid high-cost procedures and tests to maximize their compensation. Under partial- or blended-capitation models, only specific types or categories of services are paid based on capitation. ©2023 Assessment Technologies Institute, L.L.C 9  Foundational Knowledge and Basic Science: Health Care Systems and Settings MODEL DESCRIPTION Health maintenance This plan contracts with a medical center or group of providers to organization (HMO) provide preventive and acute care for the insured person. HMOs generally require referrals to specialists, as well as precertification and preauthorization for hospital admissions, outpatient procedures, and treatments. Preferred provider These plans have more flexibility than HMO plans. An insured person organization (PPO) does not need a PCP and can go directly to a specialist without referrals. Although patients can see providers in or out of their network, an in-network provider usually costs less. Point-of-service (POS) POS plans allow a great deal of flexibility for patients. They can self- plan refer to specialists and do not need an assigned PCP. Like PPO, the cost depends on whether the providers they see are within the plan’s panel. General vs. Specialty Health Care and Services General Health Care Services General practitioners (GPs) are medical doctors who treat acute and chronic illnesses and provide patients with preventive care and health education. A GP may take a holistic approach to general practice that considers the biological, psychological, and social aspects relevant to the care of each patient’s illness. Family practitioners offer care to the whole family, from newborns to older adults. They are familiar with a range of disorders and diseases. However, preventive care is their primary concern. Internists provide comprehensive care for adults, often diagnosing and treating chronic, long-term conditions. They also offer treatment for common illnesses and preventive care. Internists must have a broad understanding of the body and its ailments to diagnose conditions and provide treatment. Internists may focus on pediatric or adult medicine rather than provide care across the lifespan. Specialty Health Care Services Specialist care is used when a disease or diagnosis escalates beyond the area of expertise of a PCP. Specialists are providers focused on diagnosing and treating diseases and disorders of specific body systems. Specialist Care ©2023 Assessment Technologies Institute, L.L.C 10  Foundational Knowledge and Basic Science: Health Care Systems and Settings SPECIALIST FOCUS Allergist Evaluates disorders and diseases of the immune system, including adverse reactions to medications and food, anaphylaxis, problems related to autoimmune disease, and asthma Anesthesiologist Manages pain or administers sedation medications during surgical procedures Cardiologist Diagnoses and treats diseases or conditions of the heart and blood vessels Dermatologist Diagnoses and treats skin conditions Endocrinologist Diagnoses and treats hormonal and glandular conditions; often works with patients who have diabetes Gastroenterologist Manages diseases of the GI tract (stomach, intestines, esophagus, liver, pancreas, colon, and rectum) Gynecologist Diagnoses and treats internal reproductive system and fertility disorders Hematologist Diagnoses and treats blood and blood-producing organs, patients who have anemia, leukemia, and lymphoma Hepatologists Studies and treats diseases related to the liver, biliary tree, gallbladder, and pancreas Neonatologist Provides care of newborns, specifically those who are ill or premature Nephrologist Manages diseases and disorders of the kidney and its associated structures Obstetrician Provides care of patients during and after pregnancy Oncologist Treats and provides care for patients who have cancer Ophthalmologist Diagnoses and treats diseases and conditions of the eye Orthopedist Treats injuries and diseases of the bones, joints, muscles, tendons, and ligaments Neurologist Treats diseases and disorders of the brain and nervous system Otolaryngologist Treats diseases and conditions of the ear, nose, and throat Pediatrician Manages newborn to adolescent health ©2023 Assessment Technologies Institute, L.L.C 11  Foundational Knowledge and Basic Science: Health Care Systems and Settings SPECIALIST FOCUS Psychiatrist Diagnoses and treats mental disorders and conditions Radiologist Uses and interprets imaging to detect abnormalities in the body Urologist Manages disorders of the urinary tract Ancillary Services and Complementary Therapies Ancillary Services Providing ancillary services in the provider’s office adds convenience for patients and increases revenue for the organization. Ancillary services meet a specific medical need for a particular population. Urgent care provides an alternative to the emergency department. They cost less, have a shorter wait time, and are often conveniently located. Most have flexible hours and offer walk-in appointments. They are appropriate to use for non-life-threatening acute injuries and illnesses. Laboratory services perform diagnostic testing on blood, body fluids, and other specimens to conclude a diagnosis for the provider. Diagnostic imaging machines such as x-ray equipment, ultrasound machines, magnetic resonance imaging (MRI), and computerized tomography (CT) take images of body parts to further diagnose a condition. Occupational therapy assists patients who have conditions that disable them developmentally, emotionally, mentally, or physically. Occupational therapy helps the patient compensate for the loss of functions and rebuild to a functional level. Physical therapy assists patients in regaining mobility and improving strength and range of motion, often impaired by an accident, injury, or disease. Complementary Therapies Acupuncture involves pricking the skin or tissues with needles to relieve pain and treat various physical, mental, and emotional conditions. Chiropractic medicine diagnoses and treats pain and overall body function through spinal manipulation and alignment. Energy therapy is the calm method of clearing cellular memory through the human energy field, promoting health, balance, and relaxation. It centers on the connection ©2023 Assessment Technologies Institute, L.L.C 12  Foundational Knowledge and Basic Science: Health Care Systems and Settings between life’s physical, emotional, and mental states found in various holistic healing techniques. Dietary supplements contain one or more dietary ingredients, including vitamins, minerals, herbs, or other botanicals. A plant or part of a plant (flowers, leaves, bark, fruit, seeds, stems, roots, amino acids) is used for its flavor, scent, or potential therapeutic properties. ©2023 Assessment Technologies Institute, L.L.C 13  Foundational Knowledge and Basic Science: Basic Pharmacology Basic Pharmacology Drug Classifications, Indications, and Commonly Prescribed Medications The classification of medications is complex. Primarily, a medication’s therapeutic action dictates the classification, but sometimes it is done by chemical formulations, body systems they act on, or symptoms the medication relieves. Some medications fall into more than one category. Gabapentin and pregabalin are good examples. Both medications are anticonvulsants; they treat seizures. However, they are also analgesics because they help relieve neuropathic (nerve) pain. Another example is hydrochlorothiazide, a diuretic—it helps eliminate excess fluid from the body. However, doing so can help lower blood pressure; thus, it is also an antihypertensive medication. Here are some of the most common classifications of medications medical assistants are likely to encounter. Medication Classifications: Indications and Examples MEDICATION CLASSIFICATION INDICATION EXAMPLES analgesics relieve pain acetaminophen, hydrocodone, codeine antacids/anti-ulcer Gastroesophageal Reflux esomeprazole, calcium carbonate, Disease (GERD) famotidine antibiotics bacterial infections amoxicillin, ciprofloxacin, sulfamethoxazole anticholinergics smooth muscle spasms ipratropium, dicyclomine, hyoscyamine anticoagulants delay blood clotting warfarin, apixaban, heparin anticonvulsants prevent or control seizures clonazepam, phenytoin, gabapentin antidepressa