CCMA 3.0 Focused Review PDF

CCMA 3.0 Focused Review Professionalism Demonstrate Professionalism Professionalism is a must in a health care organization. It must be present in all aspects of the overall environment. Professionalism encompasses the following. Behaviors Appearance Communication Vo...

CCMA 3.0 Focused Review Professionalism Demonstrate Professionalism Professionalism is a must in a health care organization. It must be present in all aspects of the overall environment. Professionalism encompasses the following. Behaviors Appearance Communication Voice: tone, attitude, and word selection Written Work ethic Relationships All members of the health care team have their own roles and responsibilities that fit together to form a well-organized machine. All team members must be courteous, knowledgeable, and respectful in their presence and approach with the patient. The MA will be one of the first encounters that a patient has in the health care experience, and the first impression is important. Maintain a professional manner with a positive attitude of encouragement and support. These behaviors will help to build a relationship based on trust and respect. Professional Presence Displaying a professional presence is essential for an effective career. Other contributory factors in ensuring a professional environment include work ethic, positive and polite demeanor, willingness to assist, cooperation, and effective time management skills. Personal boundaries are essential within all relationships in the health care organization—personal relationships must be kept outside the work environment. Dress and appearance must be within the professional limits established within the field, and individual health care organizations will have policies and procedures to be followed relating to dress and appearance. When communicating, follow professional standards at all times regardless of the behavior of the other participants in the process. ©2023 Assessment Technologies Institute, L.L.C 1  CCMA 3.0 Focused Review 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  CCMA 3.0 Focused Review 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  CCMA 3.0 Focused Review 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  CCMA 3.0 Focused Review 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  CCMA 3.0 Focused Review 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  CCMA 3.0 Focused Review 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  CCMA 3.0 Focused Review 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  CCMA 3.0 Focused Review 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  CCMA 3.0 Focused Review 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. Capita on (par al or full) Pa ents are assigned a per-member, per-month payment based on age, race, sex, lifestyle, medical history, and benefit design. Payment rates are ed to expected usage regardless of how o en the pa ent visits. Like bundled payment models, providers are incen vized to help pa ents avoid high-cost procedures and tests to maximize their compensa on. Under par al- or blended-capita on models, only specific types or categories of services are paid based on capita on. ©2023 Assessment Technologies Institute, L.L.C 9  CCMA 3.0 Focused Review MODEL DESCRIPTION Health maintenance This plan contracts with a medical center or group of providers to provide preven ve organiza on (HMO) and acute care for the insured person. HMOs generally require referrals to specialists, as well as precer fica on and preauthoriza on for hospital admissions, outpa ent procedures, and treatments. Preferred provider These plans have more flexibility than HMO plans. An insured person does not need a organiza on (PPO) PCP and can go directly to a specialist without referrals. Although pa ents can see providers in or out of their network, an in-network provider usually costs less. Point-of-service (POS) plan POS plans allow a great deal of flexibility for pa ents. They can self-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  CCMA 3.0 Focused Review SPECIALIST FOCUS Allergist Evaluates disorders and diseases of the immune system, including adverse reac ons to medica ons and food, anaphylaxis, problems related to autoimmune disease, and asthma Anesthesiologist Manages pain or administers seda on medica ons during surgical procedures Cardiologist Diagnoses and treats diseases or condi ons of the heart and blood vessels Dermatologist Diagnoses and treats skin condi ons Endocrinologist Diagnoses and treats hormonal and glandular condi ons; o en works with pa ents who have diabetes Gastroenterologist Manages diseases of the GI tract (stomach, intes nes, esophagus, liver, pancreas, colon, and rectum) Gynecologist Diagnoses and treats internal reproduc ve system and fer lity disorders Hematologist Diagnoses and treats blood and blood-producing organs, pa ents 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 pa ents during and a er pregnancy Oncologist Treats and provides care for pa ents who have cancer Ophthalmologist Diagnoses and treats diseases and condi ons 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 condi ons of the ear, nose, and throat Pediatrician Manages newborn to adolescent health Psychiatrist Diagnoses and treats mental disorders and condi ons ©2023 Assessment Technologies Institute, L.L.C 11  CCMA 3.0 Focused Review SPECIALIST FOCUS Radiologist Uses and interprets imaging to detect abnormali es 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 between life’s physical, emotional, and mental states found in various holistic healing techniques. ©2023 Assessment Technologies Institute, L.L.C 12  CCMA 3.0 Focused Review 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  CCMA 3.0 Focused Review Team-Based Patient Care Team-based health care creates a partnership between providers and patients to ensure that patients are educated and actively involved in their care. Every team member is accountable for providing quality care with the shared goal of patients receiving the right care from the right person at the right time. This approach requires communication among all members of the team. Roles and Responsibilities Implementing payment models such as “pay for performance” requires a specific mindset for those delivering health care. The patient’s health is everyone’s responsibility. In organizations that practice team-based care, team members work collaboratively to provide seamless care. This allows patients to obtain the best care possible without interruptions. Everyone works at the top of their license or credential by aligning staff responsibilities to their credentials. For team-based care to be effective, multiple clinicians are needed to address all needs of the patient. Primary care providers include a provider, nurse practitioner, or physician assistant. Other health care providers include mental health specialists; physical, occupational, and speech therapists; pharmacists; nutritionists; and dentists. Patients who have chronic conditions usually have a nurse case manager to follow their health care progress, treatment, and specific needs. Support staff (medical assistants, administrative staff members) also provide valuable and essential services. Patient-Centered Medical Home The patient-centered medical home (PCMH) care delivery model coordinates patient treatment through the primary care provider to ensure the patient receives the necessary care as they need it. The goal of a PCMH is to have a centralized setting that facilitates partnerships between the patient, provider, and patient’s family (when appropriate). The long-term goal of PCMH is to improve patient outcomes and reduce costs. There are five core functions and attributes of the PCMH. PCMHs improve the patient experience through focused care and increased patient participation related to issues concerning their health care. PCMHs also save money by reducing emergency department visits, hospital admissions, and readmissions and thus provide an overall improvement in patient health. ©2023 Assessment Technologies Institute, L.L.C 1  CCMA 3.0 Focused Review PCMH Core Function and Attributes Comprehensive care is an approach that includes care for the patient’s needs— that is, the whole patient and not just certain medical and physical concerns. This involves the providers as well as the entire health care team. Patient-centered care positions patients and their families as core members of the team. The focus is on the individual needs and preferences of the patient throughout various stages of life. Coordinated care means the provider-directed medical practice oversees all specialty care, hospital, home health care, and community services. The PCMH works to create and maintain open communication between the patient and other members of the team. This is aided by information technology, such as electronic health records (EHRs). Accessible services include tools (open scheduling, extended hours, communication with providers) provided through patient information web portals. Quality and safety commitments include delivering quality health care. This is met by delivering evidence-based medicine assessed by collecting safety data and measuring and responding to patient experiences and satisfaction. Accountable Care Organizations Accountable care organizations (ACOs) are made of providers associated with a defined patient population. The providers are accountable for the quality and cost of care delivered to those patients. They are at the delivery system level in response to payment reforms instigated by the Affordable Care Act. As with PCMHs, the focus is on care coordination but with many practices within one organization. This includes multiple providers, hospitals, and specialty clinics. ACOs can also have ambulatory, inpatient, or emergency care services. Because the focus of care extends beyond the patients in medical practice, there is a relationship to the community in which the organization is located and an emphasis on public health issues to prevent illness. The ACO might have outreach programs (smoking cessation, weight loss, nutrition, online education) available to the public to promote wellness. Specific Roles of Team Members Many medical providers can be part of the health care team providing services to a patient. Primary Care Provider The primary care provider (PCP) is the first provider from whom a patient will seek care and services. One of the PCP’s main goals is coordinating preventative health care services (regular check-ups, screening, tests, immunizations, health coaching). PCPs can ©2023 Assessment Technologies Institute, L.L.C 2  CCMA 3.0 Focused Review be family practitioners, internal medicine physicians, medical doctors (MDs), doctors of osteopathy (DOs), or pediatricians. Pediatricians offer preventative care services and treat common pediatric conditions such as viral infections or minor injuries from birth through age 18 or 21. Specialist A specialist is a provider that diagnoses and treats conditions that require a specific area of expertise and knowledge. Primary care providers may refer patients to specialists to diagnose or treat a specific short-term condition. Patients may work with specialists for an ongoing period for chronic diseases. Examples of specialists include dermatologists, oncologists, cardiologists, or gynecologists. Physician Assistant/Physician Associate Physician assistants (PAs) have similar training to physicians and are licensed to practice medicine as long as a licensed doctor (MD, DO) supervises them. PAs can conduct physical exams, provide preventative care, prescribe diagnostic tests, assist with surgical procedures, diagnose illnesses, and prescribe medicine. Advance Practice Nurse Advanced practice nurses (APNs) have more education and experience than RNs and can usually perform many of the same tasks as a physician assistant. Clinical nurse specialists, nurse anesthetists, nurse practitioners (NPs), and nurse midwives are common APNs. Registered Nurse Registered nurses (RNs) are licensed by individual states and have an associate or bachelor’s degree in nursing. RNs can perform more complicated clinical tasks and usually oversee the case management of patients who have complex chronic conditions. Licensed Practical Nurse Licensed practical nurses (LPNs)—sometimes referred to as vocational nurses—are licensed by individual states. LPNs usually train for approximately 1 year at a community college or vocational school, receiving a diploma or associate degree. These health care professionals often triage phone calls, administer medications, and assist with other clinical duties in the clinical setting. Pharmacist Pharmacists prepare and dispense medications prescribed by authorized providers. They must be knowledgeable of individual and various combinations of medicines to educate patients on their use and answer questions about side effects. ©2023 Assessment Technologies Institute, L.L.C 3  CCMA 3.0 Focused Review Dentist Dentists diagnose and treat issues relating to the teeth and mouth. Dentists also educate patients on ways to prevent problems associated with oral health. Many community health centers include oral health services to patients that are free or on a sliding scale based on patient income. Therapist Some clinics offer rehabilitation services. Therapy services within the clinic are an added convenience for many patients and improve the communication process between providers and therapists. Occupational therapists assist and educate patients on performing everyday tasks after a physical, mental, or developmental disability or injury. Physical therapists assess a patient’s pain, strength, and mobility and then develop a treatment plan to improve movement and pain management. They are trained to use hands-on therapy, exercises, electrical stimulation, ultrasound, and other techniques to help improve patient movement. Speech therapists or speech-language pathologists work with patients who have problems with speech and swallowing due to an injury, cancer, or stroke. They focus on helping a person work toward improving, regaining, and maintaining the ability to communicate, chew, and swallow. They also assess and treat patients who have speech, language, voice, and fluency disorders. Psychiatrist Psychiatrists are physicians who diagnose, prescribe medications for, and treat mental, behavioral, and emotional disorders. Psychologist Psychologists are not physicians but have a Doctor of Psychology (PsyD) or a Doctor of Philosophy (PhD) degree. They work with patients experiencing mental health challenges, such as bipolar and personality disorders. Social Worker Social workers assist patients and families in times of transition or crisis. They assist patients in a clinical or hospital setting with physical, emotional, and financial issues related to an illness or injury. Social workers often coordinate additional services (transportation, housing, access to meals, financial resources, long-term care, hospice services). Providers on the mental health team that work in the PCMH or ACO usually contract with the facility to work a specific number of hours per week. Clinics with a large census can include a full-time social worker as part of their permanent staff. ©2023 Assessment Technologies Institute, L.L.C 4  CCMA 3.0 Focused Review Dietitian A registered dietitian nutritionist (RDN) is an expert in diet and nutrition. RDNs educate patients on the connection between chronic disease and nutrition, assist with menu planning, and help low-income patients obtain healthier foods at lower prices. Support Staff Administrative and clinical staff professionals are also key players in providing the best possible experience for health care consumers. Common job titles for support staff include the following. Clinic coordinator Medical administrative assistant Clinical medical assistant Medical records specialist Medical billing specialist Financial counselor Scheduler Patients and Family Members The role of the patient and family members is more essential in patient-centered health care than the traditional delivery of health care. The patient’s and family’s wants and needs are the focus areas in this type of delivery. The patient decides how they receive treatment, what those treatments will be, the desired outcome, and education and counseling to achieve these goals. Include family members and caregivers in the process if they are involved and have the patient’s approval. Effective communication is key to achieving the full participation of patients and their families. When this is successful, patients report improved symptoms and overall better outcomes. When patients feel like they are in partnership with their medical provider, they have increased satisfaction with their overall care. Fewer hospitalizations, less testing, and fewer treatments are also achieved with successful patient-family-centered health care. As a result, health care costs are also decreased. ©2023 Assessment Technologies Institute, L.L.C 5  CCMA 3.0 Focused Review Participate in the Transition of Care for Patients Transition of Care for Patients Successful transitional care occurs when there is appropriate coordination and continued quality in health care as a patient moves from one care provider to another. Lack of communication between providers regarding patient histories, medication therapies, and overall patient needs is directly associated with an increased risk of rehospitalizations, adverse clinical events, increased spending, and poor quality of care. To overcome these shortfalls, communicate effectively with the referring provider, other providers, and the patient. Educating patients regarding managing their own care and encouraging the patient and their family members to take an active role in health care decisions is empowering and leads to more adherence. The key is excellent communication between the primary care provider, patient, and new or additional providers associated with the patient’s care. Resources and Procedures to Coordinate Care and Outpatient Services Coordinating Care With Community Agencies Many services within the community can benefit patients. Be cognizant of what services are offered and provide contact information for those services to patients who will benefit from them. Brochures from organizations are usually free and available to hand out. Keep a list of community resources in an easily accessible location so that information can be provided to patients without any delays. Depending on the specialty of the practice, lists can be organized according to patient condition, age, or socioeconomic status. The Centers for Disease Control and Prevention (CDC) website has resources that provide services within specified geographic locations. Local hospital websites also provide information regarding outreach programs offered in the community. Document all information provided to the patient in the health record to promote continuity of care. ©2023 Assessment Technologies Institute, L.L.C 1  CCMA 3.0 Focused Review Teamwork Facilitate Teamwork and Team Engagement Effective teamwork and engagement are a must for any health care organization. They contribute to the flow of a positive environment, which helps ensure patient satisfaction. Each member of the health care team makes an impact on the overall health care experience for patients. Each member performs their own responsibilities, and the members work together to ensure that all tasks are completed. Gossip, negative tone and word use, and dramatic outbursts have no place in the work environment. While personal feelings related to workplace events and interactions are expected, health care professionals must not allow those feelings to hinder their professionalism or the way in which they provide patient care. Working together in a cooperative environment helps to engage each of the team members, which increases the patient satisfaction levels. Quality health care services are provided to patients by a team that works well together where each member is involved in the process. ©2023 Assessment Technologies Institute, L.L.C 1  CCMA 3.0 Focused Review 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 medica on name Full medica on name Nitro Nitroglycerin u, U, IU Units ©2023 Assessment Technologies Institute, L.L.C 1  CCMA 3.0 Focused Review DO NOT USE USE INSTEAD x3d mcg or microgram cc mL Apothecary units Metric units od, O.D., OD Daily or intended me of administra on q.d, qd, Q.D, QD, q1d, i/d Daily q.o.d., QOD Every other day Q6PM 6 p.m. daily TIW, w 3 mes weekly HS half-strength, bed me (hour of sleep) SC, SQ, sub q subcutaneously IN intranasal IJ injec on OJ orange juice @ at &, + and / per AD, AS, AU right ear, le ear, both ears OD, OS, OU right eye, le eye, both eyes D/C, dc, d/c discharge or discon nue ©2023 Assessment Technologies Institute, L.L.C 2  CCMA 3.0 Focused Review 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 Abbrevia ons and Acronyms ABBREVIATION/ ABBREVIATION/ ACRONYM MEANING ACRONYM MEANING Abd Abdomen C Celsius ABGs Arterial blood gases C&S Culture and sensi vity a.c. Before meals Ca Calcium; cancer ACLS Advance cardiac life support CABG Coronary artery bypass gra Ad lib As desired CAD Coronary artery disease ADHD Aten on deficit hyperac vity CBC Complete blood count disorder AKA Above-the-knee amputa on CC Chief complaint AMA Against medical advice CDC Centers for Disease Control and Preven on ASA Aspirin cm Cen meter ©2023 Assessment Technologies Institute, L.L.C 3  CCMA 3.0 Focused Review 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 amputa on CP Chest pain BM Bowel movement CPR Cardiopulmonary resuscita on BMI Body mass index c/o Complains of BP Blood pressure COPD Chronic obstruc ve pulmonary disease BPH Benign prosta c hypertrophy Csf Cerebrospinal fluid 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 Dila on and curetage D/C, dc Discharge, discon nue 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 acellular I&D Incision and drainage pertussis vaccine Dx Diagnosis I&O Intake and output ©2023 Assessment Technologies Institute, L.L.C 4  CCMA 3.0 Focused Review ABBREVIATION/ ABBREVIATION/ ACRONYM MEANING ACRONYM MEANING 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 le FBS, FBG Fas ng blood sugar/glucose lb Pound f/u Follow up LLE Le lower extremity FUO Fever of unknown origin LLL Le lower lobe Fx Fracture LLQ Le lower quadrant GI Gastrointes nal LMP Last menstrual period GTT Glucose tolerance test LUE Le upper extremity gt Drop LUQ Le upper quadrant GU Genitourinary Mg/dl Milligrams per deciliter GYN Gynecology, gynecologist MI Myocardial infarc on H, hr Hour mL Milliliters Hct Hematocrit MM Mucous membrane HEENT Head, ears, eyes, nose, throat mm Hg Millimeters of mercury HF Heart failure MRI Magne c resonance imaging Hgb Hemoglobin MS Mul ple sclerosis HIPAA Health Insurance Portability and N/V Nausea/vomi ng Accountability Act ©2023 Assessment Technologies Institute, L.L.C 5  CCMA 3.0 Focused Review ABBREVIATION/ ABBREVIATION/ ACRONYM MEANING ACRONYM MEANING NB Newborn RLL Right lower lobe NG Nasogastric RLQ Right lower quadrant NKA/NKDA No known allergies/No known drug R/O Rule out allergies NPO Nothing by mouth (nil per os) ROM Range of mo on NS Normal saline RT Respiratory therapy/therapist NSAID Nonsteroidal an -inflammatory RUE Right upper extremity drug OB Obstetrics RUQ Right upper quadrant OC Oral contracep ve Rx Prescrip on OOB Out of bed s̄ Without OP Outpa ent SOB Shortness of breath OT Occupa onal therapy/therapist Stat Immediately OTC Over-the-counter STI Sexually transmited infec on PA Posteroanterior, physician assistant Sx Symptoms p.c. A er meals (post cibos) T&A Tonsillectomy and adenoidectomy PE Physical examina on, pulmonary TB Tuberculosis embolism PID Pelvic inflammatory disease TIA Transient ischemic atack PMS Premenstrual syndrome Tx Treatment PO By mouth UA Urinalysis PRN As needed URI Upper respiratory infec on ©2023 Assessment Technologies Institute, L.L.C 6  CCMA 3.0 Focused Review ABBREVIATION/ ABBREVIATION/ ACRONYM MEANING ACRONYM MEANING PT Physical therapy/therapist UTI Urinary tract infec on pt Pa ent VS Vital signs R Right WBC White blood cell RA Rheumatoid arthri s 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 ↓ Decrease ♂ Male ♀ Female ‘ Feet ©2023 Assessment Technologies Institute, L.L.C 7  CCMA 3.0 Focused Review SYMBOL MEANING “ 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 Endocrine WORD ROOT MEANING Aden Gland Pancreat Pancreas Thyr Thyroid gland ©2023 Assessment Technologies Institute, L.L.C 8  CCMA 3.0 Focused Review Hematologic WORD ROOT MEANING Hem, hemat Blood Phleb Vein Thromb Clot Musculoskeletal WORD ROOT MEANING Arthr Joint Brachi Arm Cervic Neck Chondr Car lage Cost Rib Crani Skull Dactyl Finger or toe Fibr Connec ve ssue My Muscle Oste Bone Pod Foot Sacr Sacrum Spondyl, vertebr Vertebra ©2023 Assessment Technologies Institute, L.L.C 9  CCMA 3.0 Focused Review WORD ROOT MEANING Ten, tendin Tendon Gastrointes nal WORD ROOT MEANING Abdomin Abdomen An Anus Appendic Appendix Bil, chol Bile, gall Col Colon Dent Teeth Enter Intes nes Esophag Esophagus Gastr Stomach Gingiv Gums Gloss Tongue Hepat Liver Icter Jaundice Ile Ileum Lapar Abdominal wall Lingu Tongue Pancreat Pancreas ©2023 Assessment Technologies Institute, L.L.C 10  CCMA 3.0 Focused Review WORD ROOT MEANING Pepsia Diges on Phag Ea ng, swallowing Proct Rectum Splen Spleen Stomat Mouth Genitourinary/Reproduc ve WORD ROOT MEANING Andr Male Colp Vagina Cyst Bladder Gravid Pregnant Gynec Female Hyster Uterus Mamm, mast Breast Metr Uterus Nephr Kidney Ov Ovum Oophor Ovary Orchid Tes cles Prostat Prostate gland ©2023 Assessment Technologies Institute, L.L.C 11  CCMA 3.0 Focused Review WORD ROOT MEANING 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 Steth Chest Thorac Thorax Trache Trachea ©2023 Assessment Technologies Institute, L.L.C 12  CCMA 3.0 Focused Review 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 Neurologic WORD ROOT MEANING Blephar Eyelid Cephal Head Cerebr Cerebrum Encephal Brain ©2023 Assessment Technologies Institute, L.L.C 13  CCMA 3.0 Focused Review WORD ROOT MEANING Esthesi Sensa on 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 por on of the body Gluc, glyc Sugar Hemi Hernia Hist Tissue Hydra Water Lact Milk ©2023 Assessment Technologies Institute, L.L.C 14  CCMA 3.0 Focused Review WORD ROOT MEANING 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 Sep c Infec on Therm Heat Combining Root Words 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. ©2023 Assessment Technologies Institute, L.L.C 15  CCMA 3.0 Focused Review Combining Form Examples WORD ROOT COMBINING VOWEL COMBINING 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- Excep onally large Ab- Away, from Meso- Middle Ad- Toward Meta- Over, beyond Ambi- Both Micro- Small Ante- Before Mono- One An - Against Mul - Many Auto- Self Neo- New ©2023 Assessment Technologies Institute, L.L.C 16  CCMA 3.0 Focused Review PREFIX MEANING PREFIX MEANING Bi- Two, twice, double Nulli- None Brady- Slow Peri- Around Circum- Around Poly- Many Contra- Against Post- A er, 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-, exo- Outside of Retro- Behind, in back of Hemi- Half Sten- Narrowed Hyper- Above, excessive, Sub- Under increased Hypo- Below, decreased, Super-, supra- Above, excess insufficient Infra- Beneath Sym-, syn- Together, with Inter- Between, among Tachy- Fast Intra- Within, during Trans- Across Levo- To the le Tri- Three Macro- Large Ultra- Beyond, excess Mal- Bad Uni- One ©2023 Assessment Technologies Institute, L.L.C 17  CCMA 3.0 Focused Review 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 -logy, logist Study of, one who studies -ole Litle, small -opia Vision -phylaxis Protec on, preven on -pnea Breathing -therapy Treatment -uria Urine ©2023 Assessment Technologies Institute, L.L.C 18  CCMA 3.0 Focused Review Surgery/Procedures SUFFIX MEANING -centesis Surgical puncture -cise Cut, remove -clasis Break down -desis Stabiliza on, binding -ectomy Removal, excision -gram Record -graph Instrument for recording -graphy Process of recording -ion Process -lepsy Seizure, convulsion -lysis Destruc on, separa on -meter Device for measuring -metry Process of measuring -pexy Fixa on, to put in place -plasty Surgical repair, reforma on -scopy Visual examina on -spasm Involuntary twitch -stasis Stopping or controlling -stomy A new opening -tomy Incision ©2023 Assessment Technologies Institute, L.L.C 19  CCMA 3.0 Focused Review SUFFIX MEANING -tripsy Crushing Disorders/condi ons SUFFIX MEANING -algia Pain -asthenia Weakness -cele Swelling, hernia on -dynia Pain -ectasis Dila on, expansion -emesis Vomi ng -emia Blood condi on -gen Producing -ia, -ism Condi on of -iasis Presence of, forma on of -I Inflamma on -malacia Weakening or so ening of -mania Obsessive preoccupa on -megaly Enlargement -oid Seeming like -ole Small -oma Tumor ©2023 Assessment Technologies Institute, L.L.C 20  CCMA 3.0 Focused Review SUFFIX MEANING -osis Condi on, usually abnormal -pathy Disorder, disease -penia Deficiency, decrease -phagia Ea ng, swallowing -phasia Speech -phobia Fear -plasia Forma on of -plegia Paralysis -ptosis Drooping, falling -rrhage Burs ng forth -rrhea Flow, discharge -rrhexis Rupture -sclerosis Hardening condi on -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 21  CCMA 3.0 Focused Review Medical Terms MEDICAL TERM LAY LANGUAGE Hypertension High blood pressure Angina Chest pain Acute New, urgent, sudden Chronic Ongoing Alopecia Hair loss Cerebrovascular accident (CVA) Stroke Myocardial infarc on Heart atack Edema Swelling CT scan CAT scan Cryotherapy Freezing off Abdomen Stomach Tachycardia Fast heart rate, heart bea ng fast, heart racing Bradycardia Low heart rate, heart bea ng slow Hyperglycemia High blood sugar Hypoglycemia Low blood sugar GERD Heartburn Shortness of breath Trouble breathing Phalanges Fingers and toes Arrhythmia Irregular heart rhythm Erythrocytes Red blood cells ©2023 Assessment Technologies Institute, L.L.C 22  CCMA 3.0 Focused Review MEDICAL TERM LAY LANGUAGE Ver go Dizziness, room spinning, dizzy, lightheaded Syncope Fain ng, temporary loss of consciousness Deep vein thrombosis (DVT) Blood clot Osteoarthri s Wear and tear Amyotrophic lateral sclerosis (ALS) Lou Gehrig’s disease 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 posi on 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 posi on Si ng upright with back angled at 90 degrees Semi-Fowler’s posi on Si ng with back angled at 45 degrees TERM DEFINITION Anterior Toward the front of the body, also known as ventral. Posterior Toward the back of the body, also known as dorsal. ©2023 Assessment Technologies Institute, L.L.C 23  CCMA 3.0 Focused Review TERM DEFINITION 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 le ©2023 Assessment Technologies Institute, L.L.C 24  CCMA 3.0 Focused Review Adhere to Standard and Universal Precautions and Guidelines Related to Infection Control Universal precautions and guidelines are set in place to prevent health care professionals from exposure to infections when providing first aid or health care. These guidelines include considering each patient potentially infectious for blood-borne pathogens including but not limited to human immunodeficiency virus (HIV) and the hepatitis B virus. Universal Precautions Universal precautions apply when in possible contact with any of the following. Blood products Human tissue Body fluids such as cerebrospinal fluid, amniotic fluid, and pleural fluid Any body fluid visibly contaminated with blood Vaginal secretions and semen Standard Precautions Health care professionals are responsible not only for protecting their patients but also for protecting themselves from blood-borne pathogens. The Centers for Disease Control and Prevention has been recommending standard precautions since 1987. Protecting the health care professional against exposure to blood and other body fluids is essential when the status of infection is unknown in a patient. Some general guidelines are as follows. Wash hands before and after every procedure. Use gloves with encountering patient blood/body fluids, handling anything contaminated with blood, performing venipuncture, handling blood specimens, and cleaning up body fluids or blood. Cover any scratches or breaks in the skin. Refrain from eating, drinking, or chewing gum while working. ©2023 Assessment Technologies Institute, L.L.C 1  CCMA 3.0 Focused Review Wear appropriate personal protective equipment (PPE) if blood or body fluid splatter could occur. Clean all spills immediately with appropriate cleaning supplies. Dispose of sharps immediately. Place sharps or broken glass in a puncture-proof container. Dispose of all biohazard waste in appropriate biohazard container. ©2023 Assessment Technologies Institute, L.L.C 2  CCMA 3.0 Focused Review Adhere to Regulations and Guidelines Related to Infectious Diseases There are three categories for job tasks and the potential for exposure to blood borne pathogens. They are determined by how much exposure to potential infectious agents you would likely encounter. Task Categories Category I - Tasks that have a chance of body fluids or blood spilling or splashing, or tasks that can cause exposure to blood or body fluids such as a minor surgical procedure Category II - Tasks that do not usually involve chance of exposure, such as CPR; precautions must still be taken Category III - Tasks that do not require any PPE, such as taking a patient’s vital signs CDC Guidelines for Infectious Disease (Prevention, Reporting) If a health care professional has a fever or feels sick, refrain from contact with patients to reduce the risk of spread. Stay home and only return to work if the MA has been fever-free for at least 24 hours without the use of any fever-reducing medications. OSHA also outlines standard safeguards to take when performing specific medical tasks. The Needle Safety and Prevention Act was signed into law in November 2000. Health care professionals must implement the use of devices that help reduce the risk of needlestick injuries such as needle safety devices. Facilities must also maintain a detailed logbook of any needlestick or sharps injuries from dirty or contaminated sharps. Health care facilities must also implement work practice controls to help reduce the risk of injury at work by altering the way a task is performed. Approaches for the Control of Infectious Diseases, Epidemics, and Pandemics Additional precautions may need to occur when working with a patient with a suspected infection. These guidelines are known as transmission-based precautions. This is broken down into three categories. Contact precautions: Transmission through direct and indirect touching; using proper PPE such as gloves and gown, washing hands before and after working with the patient, and disinfecting the exam room are all precautions that should be taken. ©2023 Assessment Technologies Institute, L.L.C 1  CCMA 3.0 Focused Review Droplet precautions: Transmission by contact of secretions and usually occurs when an infected person coughs or sneezes; get the patient to an exam room as quickly as possible, have the patient put on a face mask, and have the health care professional use appropriate PPE such as mask and gloves. Airborne precautions: Transmission by infectious agents floating in the air, which can expose anyone around the patient; allow the patient to enter the facility by a different route, place the patient in an isolation room, have the patient place a face mask on, and have the health care working use appropriate PPE such as mask, gloves, and gown. Guidelines for Exposure to Bloodborne Pathogens (OSHA, American Hospital Association [AHA]) The Occupational Safety and Health Administration (OSHA) established a blood-borne pathogen standard to reduce the risk of occupational exposure to infectious disease. Exposure can occur in several ways: needlesticks; cuts; or blood or bodily fluid coming into contact with the eyes, nose, mouth, or other non-intact skin. One component of this standard requires employers to have a written exposure control plan to protect their employees who have the potential for exposure based on their job duties and responsibilities. The Centers for Disease Control and Prevention has outlined health care personnel that are considered “at risk” for occupational exposure to bloodborne pathogens including hepatitis B and C virus as well as human immunodeficiency virus (HIV). Employers are required to update their exposure control plan annually to align with changes that help reduce the potential for exposure. The following must be detailed in the employer’s exposure control plan. Engineering Controls Devices used to isolate or remove the blood-borne pathogen hazard from the workplace. Workplace Controls Practices in the workplace that reduce the chances of exposure by changing or mandating the way a task is performed. PPE Employers must provide personal protective equipment to employees. Hepatitis B Vaccinations Employers must provide hepatitis B vaccinations to all employees with a risk of exposure within 10 days of employment, at no cost to the employee. Documentation of the offer or a vaccination record for the employee must be kept on file. ©2023 Assessment Technologies Institute, L.L.C 2  CCMA 3.0 Focused Review Post-Exposure Follow-Up Employers must follow up with any professional who had an exposure incident at no cost to the employee. All employee diagnoses must remain confidential. Labels and Signs to Communicate Hazards Labels are required to be on all regulated waste and storage containers containing potentially infectious materials. Information and Training to Employees Employers must provide regular training that covers the dangers of blood-borne pathogens, preventive practices, and post-exposure procedures. This training must be provided on initial hire and annually thereafter. Documented Employee Medical Training Records Medical training and records must be maintained for each employee, in addition to a log of occupational injuries and illnesses and a sharps injury log. ©2023 Assessment Technologies Institute, L.L.C 3  CCMA 3.0 Focused Review Follow Guidelines Related to Use of PPE Following specific guidelines on how to don (put on) and doff (remove) various PPE helps stop the spread of infectious agents. Gloves are the most used PPE in a health care setting. Donning Nonsterile Gloves Perform handwash. Select appropriate size of nonsterile gloves. Place hand through opening and pull glove up to wrist. Repeat on other hand. Adjust gloves as necessary. Doffing Nonsterile, Contaminated Gloves Grasp palm of glove of nondominant hand with dominant hand. Pull glove off the nondominant hand in a downward motion while turning the glove inside out. Hold in dominant hand. Roll the glove up into the dominant hand. Place two fingers of the ungloved hand under the cuff of the other gloved, dominant hand, making sure not to touch the outside of the glove. Pull the glove over the hand, turning it inside out over the other glove. Throw away the gloves in the appropriate container. Wash hands. ©2023 Assessment Technologies Institute, L.L.C 1  CCMA 3.0 Focused Review Adhere to Guidelines Regarding Hand Hygiene Good hand hygiene can be a major contributor that stops the cycle of infection in both clinical and nonclinical settings and is the single most important factor in preventing the spread of pathogens. Both medical professionals and patients benefit from this essential and simple safety practice. Clinical staff are discouraged from wearing excess jewelry such as rings and bracelets; a single plain band is often the exception. These items can harbor pathogens, which makes asepsis difficult to achieve. Artificial nails should also not be worn in a clinical setting. Research has shown that health care professionals who wear artificial nails have more bacteria on their nails than those with natural nails. Alcohol-based hand sanitizers can be used in certain situations to help stop the infectious cycle—for example, if a sink is not available. Health care professionals should wash hands with soap and water when hands are visibly contaminated or dirty. Alcohol-based sanitizer can be used on hands that are not visibly soiled. CDC Hand Hygiene Recommendations Proper hand hygiene must be used in the following situations even if disposable gloves are used. Additional times to use hand hygiene include the following. After using the restroom (soap and water) Before and after eating (soap and water) When arriving and before leaving work (soap and water) Handwashing Techniques Remove all jewelry except a plain ring or band. Turn on the faucet and regulate the water temperature to lukewarm. Wet the hands, apply approximately 3 milliliters or 3 pumps of soap, and lather using a circular motion with friction while holding the fingertips downward. The friction that is created with this step helps to lift debris from the skin. Rub hands well while interlacing fingers together to create friction and use circular motions around wrist. This process should be continued for at least 20 seconds. Microbes tend to concentrate near and under the nails, so pay special attention to those areas, ensuring the water is flowing down from the wrist to the fingertips. Rinse the hands a second time, always keeping fingers lower than the wrist. Dry both hands with paper towels. Do not touch the paper towel dispenser when obtaining the towels. If an automated paper towel dispenser is not available, make sure to have paper towels ready prior to beginning handwashing. If the faucets are not foot ©2023 Assessment Technologies Institute, L.L.C 1  CCMA 3.0 Focused Review operated, turn them off with a dry paper towel. Discard the paper towel in a covered waste container. Alcohol-Based Rubs/Sanitizer In certain circumstances and when hands are not visibly soiled, an alcohol-based sanitizer with a minimum of 60% alcohol can be used. Start by pushing watch and uniform sleeves above wrists and removing rings. When using an alcohol-based sanitizer, dispense proper amount per manufacturer’s recommendations into the palm of one hand. Rub both hands together, creating friction, making sure to cover all surfaces, including palms, backs of hands, fingers, and between fingers. Continue rubbing until the solution has dried. Keep in mind that sanitizers can be a good solution in specific circumstances, but they cannot be used to replace washing hands when they are visibly dirty. In this situation, soap and water must be used to remove the debris and wash the hands. ©2023 Assessment Technologies Institute, L.L.C 2  CCMA 3.0 Focused Review Dispose of Biohazardous Materials as Dictated by Occupational Safety and Health Administration (OSHA) (Sharps Containers, Biohazard Bags) To make sure certain biohazardous materials do not harm the environment or individuals, OSHA has set specific laws to specify how you must handle infectious waste according to the OSHA Bloodborne Pathogens Standard of 1991. Although OSHA enforces these laws, it is up to the medical facility to guarantee the laws are being followed. The use of PPE and Safety Data Sheets (SDSs) provides the health care professional with the tools and resources to maintain a safe clinical work environment. The proper identification of any potentially infectious waste materials and disposal of contaminated material is another step in preventing the spread of infectious material. Cautions Related to Chemicals The medical assistant must be familiar with all chemicals used in the office and proper precautions when using them. Some general precautions to keep in mind include wearing protective eyewear and other PPE to prevent damage to skin. Also, be careful when carrying chemicals by using both hands and working in a well-ventilated area. An eye wash station should be accessible in the lab. It is recommended that staff knows the location of the eyewash station and how to properly use it. Eyewash stations should be inspected monthly to ensure they are in proper working order. Disposal Methods Any item that likely contains infectious waste material must be disposed of properly in a biohazard waste container. Some examples of items are blood products, bodily fluids, sharp instruments, gauze containing body fluids, and contaminated gloves. There are a variety of biohazard waste containers that are used for different infectious waste materials. The following guidelines must be followed when handling biohazard materials. Wear proper PPE, including gloves. Immediately place biohazard materials in appropriate receptacle. Keep containers upright and closed. Drop items into sharps containers and avoid pushing them in. Discard of disposable sharps container when it has reached the fill line. Never recap needles. Rather, place them in a sharps container immediately after use on a patient. Any item that has sharp edges or blades, such as a scalpel, should also be disposed of in ©2023 Assessment Technologies Institute, L.L.C 1