Download Document

Pearson's Comprehensive
Medical Assisting
Administrative and Clinical Competencies
Second Edition
CHAPTER
CHAPTER
3
Medical Law and Ethics
Lesson 3:
Documentation and Regulations
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Lesson Objectives
Lesson Objectives
Upon completion of this lesson, students
should be able to …
• Discuss the role of the medical assistant
relating to legal issues in the medical
office.
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Documentation
• It is critical to carefully document what
happens in the medical office.
If an action is not recorded on the medical chart, then it is
considered by the court not to have been performed.
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Critical Thinking Questions
1. Why is documentation so important?
2. Give some examples.
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Information Documented in a
Patient’s Chart
•
•
•
•
•
•
•
•
Calls and visits
Treatments
No-shows
Appointment
cancellations
Medications
Prescription refills
Vital signs
Other pertinent
information
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
When a Medical Record is
Subpoenaed for Court
• Copy only the parts of the record that are
requested and sent
• Send a certified copy unless the original
record is subpoenaed
• If original is subpoenaed, make a copy and
return copy to file
• Place a receipt for the subpoenaed record in
the patient’s file
• Notify the patient by certified mail that the
records have been subpoenaed
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Cautions with Documentation
• Be careful with fax transmissions of
medical records – avoid it
• Receiving fax must be located in a
restricted area
• A disclaimer should be placed on the fax
cover explaining that records are
confidential
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Court Testimony
• Information is gained from a witness by:
– Interrogation by an attorney (interview)
– Submission of a deposition (written
documentation of an oral statement in front of
a court officer)
– Testifying in court
• Expert witness
– Testifies about standard of care
– Typically a physician
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Court Testimony
• If you are asked to testify in court…
– Be professional
– Remain calm, dignified, and serious
– Always tell the truth
– Do not answer questions you do not
understand
– Do not memorize your testimony ahead of
time
– Just present the facts about the case
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Reports Physicians Must Provide
•
•
•
•
•
•
•
•
•
Births
Stillbirths
Deaths
Communicable illnesses or diseases
Drug abuse
Certain injuries
Abuse of child and adults
Gunshot and knife wounds
Animal bites
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Birth Certificate
• Physicians have a duty to issue a legal
certificate of birth
• Used as a legal proof of age
• Required for many benefits and
documents:
– Social security
– Passport
– Driver’s license
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Death Certificate
• Physicians have a duty to issue a legal
certificate of death for natural deaths
• Each state has specific requirements
• A coroner or health official will have to sign
a death certificate in the following cases:
– No physician present at the time of death
– Violent or unlawful death
– Death as a result of criminal action
– Death from an undetermined cause
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Critical Thinking Question
1. What is the purpose of a death
certificate?
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Reportable Communicable
Diseases
• Physicians have a duty to report all
diseases that can be transmitted from one
person to another and are considered a
general threat to the public
• Each state has specific reporting
requirements
• Physicians can either mail or phone in the
report
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Critical Thinking Question
1. Why is the reporting of communicable
diseases necessary and required?
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Childhood Vaccines and Toxoids
Required by Law
• Diptheria, tetanus toxoids, pertussis
vaccine (DTP)
• Pertussis vaccine (whooping cough)
• Measles, mumps, rubella (MMR)
• Poliovirus vaccine, live
• Poliovirus vaccine, inactivated
• Hepatitis B vaccine
• Tuberculosis test
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Critical Thinking Question
1. Why might the government require
childhood vaccines?
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Reportable Injuries
• Physicians have a duty
to report certain injuries
• Requirements differ by
state
• Injuries include:
– Gun or knife wounds
– Rape and battered
persons injuries
– Spousal abuse
– Child abuse
– Elder abuse
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Critical Thinking Question
1. Why is the reporting of injuries necessary
and required?
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Child Abuse
• Physicians have a
duty to report
questionable injuries
of children
• Requirements differ
by state
• These injuries
include:
–
–
–
–
–
–
Bruises
Fractured bones
Burns
Malnutrition
Poor growth
Lack of hygiene
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Critical Thinking Question
• Why is the reporting of child abuse
necessary and required?
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Elder Abuse
• Physicians have a duty to report
questionable injuries of the elderly
• These requirements include:
– Physical abuse
– Neglect
– Abandonment
• Requirements differ by state
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Critical Thinking Question
1. Why is this reporting of elder abuse
necessary and required?
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Drug Abuse
• Abuse of prescription
drugs must be reported
• Abuse may be difficult
to determine since a
patient may go to
several different
doctors for the same
drug
• A physician should
always see the patient
before prescribing
drugs
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Drug Regulation Agencies
• Food and Drug Administration (FDA)
– Federal agency
– Has jurisdiction over testing and approving drugs for
public use
• Drug Enforcement Administration (DEA)
– Branch of the Justice Department
– Regulates the sale and use of schedule drugs
To visit these organizations go online to:
http://www.fda.gov and
http://www.usdoj.gov/dea/index.htm
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
What the FDA Regulates
•
•
•
•
•
•
•
Biological products
Cosmetics
Drugs
Foods
Medical devices
Radiation-emitting electronic products
Veterinary products
Click here to see more detail or visit www.fda.gov
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
What the FDA Does Not Regulate
•
•
•
•
•
•
•
•
•
Advertising
Alcohol
Consumer products
Drugs of abuse
Health insurance
Meat and poultry
Pesticides
Restaurants and grocery stores
Water
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Critical Thinking Question
1. Who regulates each of these areas not
regulated by the FDA?
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
The DEA
• Has the responsibility of enforcing
controlled substances laws and
regulations
• Provides many resources and services:
– Drug information
– Drug photos
– DEA Most-wanted fugitive list
– Threat assessment information
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Other Resources and Services of
the DEA
• Stats and facts
• Criminal cases against doctors
• Drug prevention programs
To watch an example of drug prevention related
to DXM prevention click here or visit
http://www.dxmstories.com/index.html
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Form DEA 224
• Used by physicians to register with the
DEA
• Allows physicians to prescribe, dispense,
or administer controlled substances
• Renewal is required every 3 years
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Requirements for Controlled
Substances
• Controlled drugs must be kept in a doublelocked cabinet
• Any theft must be immediately reported to
both regional DEA office and local police
• Physician’s black bag and prescription
blanks should always be stored in a
secure, locked location
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Requirements for Controlled
Substances Records
• Records must be kept to document the
administering and dispensing of controlled
drugs
• Federal regulations require a written
inventory in triplicate of drug supplies
– Inventory is based on daily use
– Required every 2 years
– Required to be kept for two more years
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Schedule for Controlled
Substances
• Schedule I
– Highest potential for addiction and abuse
• Schedule II
– High potential for addiction and abuse
• Schedule III
– Moderate to low potential for addiction and abuse
• Schedule IV
– Lower potential than Schedule III drugs
• Schedule V
– Low potential for addiction and abuse
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Common Controlled Substances
•
•
•
•
•
•
•
•
•
Anabolic steroids
Butabarbital
Chloral hydrate
Cocaine
Codeine
Diazepam
Heroin
LSD
Marijuana
•
•
•
•
•
Morphine
Opium
Phenobarbital
Secobarbital
Tylenol with codeine
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Role of the Medical Assistant
• Does not dispense controlled substances
• Must be knowledgeable about the
regulations governing the documentation
and control of the drugs
• Only licensed personnel are permitted to
dispense drugs
• Always report any unusual patient
behavior indicating addictive drug use
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Critical Thinking Question
1. A physician is dispensing morphine to a
patient whom you suspect is addicted to
the drug. You suspect the physician of
illegally dispensing this drug for a
nonexistent problem. What do you do?
2. You come to work one day and notice
that the lock for the controlled substance
cabinet has been tampered with. What
do you do?
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Role of the Medical Assistant
• Critical in preventing liability suits
• Sometimes the only person who hears a
patient’s complaint or issue
• Needs to know how to handle situations in
a professional and efficient manner
• Responsible for always acting within the
Code of Ethics
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Ways to Help Your Employer
• Follow the chain of
command
• Report to your
immediate supervisor
any negligent action
you observe
• If you make an error,
bring it to your
supervisor’s attention
immediately so that it
can be corrected
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
MA’s Role Related to
Confidentiality/Privacy Issues
• Never make any statements about your
employer that could be interpreted as an
admission of fault
• Do not remain silent if you are aware that
your employer is doing something illegal
• Do not participate in negative or critical
discussions of the physician with patients
If you are aware of illegal activity and remain
silent, you may be liable.
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
MA’s Role Related to
Confidentiality/Privacy Issues
• Do not comment on a
patient’s negative criticism
of a current or former
physician
• Never discuss anything
about the patient outside of
the office
• Make sure that a female MA
is present when the
physician (male or female)
examines a female patient
• Treat all patients with
dignity and respect
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
MA’s Role Related to Office
Management
• Treat all patients with the
same courtesy and
dignity you would expect
to receive
• Log and return telephone
calls promptly
• Explain any delays to
patients who are waiting
to see the physician
• Offer to set up another
appointment if the delay
will be very long
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
MA’s Role Related to Office
Management
• Never make promises
regarding what the
physician can do for the
patient
• Carefully explain all fees
and responsibilities for
bills to the patient
• Relay any concerns
about bills from the
patient to the physician
• Relay any dissatisfied
patient comments to the
physician
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
MA’s Role Related to Office
Management
• If the physician will be out
of town or absent from
the office, post these
dates and include an
announcement in the
monthly billing envelopes
• Provide the name and
telephone number of the
physician available for
patients who need care
when their own physician
is absent
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
MA’s Role Related to Office
Management
• If the physician is withdrawing from a case,
then send a letter informing the patient
• Send the letter via certified mail with return
receipt requested
• Keep a copy of the letter and receipt with the
patient’s record
A physician can be brought up on charges of
abandonment if there is no documentation or evidence
that there was a formal withdrawal.
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
MA’s Role Related to
Documentation
• Carefully sign or initial every note
• If the patient did not keep an appointment, be
sure to document the fact as a no-show
• Follow up to determine why the patient missed
the appointment
• Document when a patient is referred to another
physician
• Follow up to make sure the patient did see the
referral physician
Medical documents are legal documents and may be
used in a court of law.
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
MA’s Role Related to
Documentation
• Document all patient
contracts, including
telephone prescription
refills and tests and
procedures that have
been ordered
• Call all patients the
day after surgery to
check on their
progress and
document this call
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
MA’s Role Related to
Documentation
• Record all care and
treatment given as
soon as possible after
the patient’s visit
• Be sure the physician
sees and initials all
diagnostic reports in a
timely fashion before
they are filed
• Provide all patient
instructions in writing
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
MA’s Role Related to Drug
Regulations
• May administer
medication only under the
direct supervision of a
physician
• Follow the Controlled
Substances Act by
carefully following
procedures and
documenting actions
• Know state laws
• Secure the supply of
prescription pads from
theft at all times
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
MA’s Role Related to Drug
Regulations
• When preparing
medications for
administration, check
the medication three
times:
– Before removing it
from the shelf
– Again, before
preparing the dosage
– Before returning the
medication to the shelf
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
MA’s Role Related to
Certification and Licensing
• Know the limits of
certification and standards
of care for your profession
• Never perform any
procedures for which you
are not trained or qualified
• Do not diagnose or
prescribe drugs over the
telephone (even OTC
drugs)
• Do not call yourself a
“nurse” or allow anyone
else to refer to you as one
Continue your education and
training to maintain your skill
levels.
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
MA’s Role Related to Informed
Consent
• Physician must thoroughly
explain all procedures to the
patient
• MA is responsible for
making sure there is a
signed consent form
• Never have a patient sign a
document that he or she
does not understand
• Obtain a parent/guardian’s
signature before providing
care to a minor except in
the case of an emergency
File signed informed
consents immediately!
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
MA’s Role Related to Safety
Issues
• Maintain a safe
environment in the
office for the patients
and staff
• Handle requests for
maintenance repairs
• Report any safety
hazards at once
Remove needle from syringe
and dispose of in sharps
container.
If you knowingly overlook a hazard you could be found
guilty of negligence!
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
MA’s Role Related to Safety
Issues
• Carefully check and
document medical waste
disposal
• Be concerned about the
safety of maintenance
personnel who must
handle waste containers
• Always dispose of
syringes and needles
correctly in designated
hazardous waste
containers
• Maintain and document
careful quality checks on
laboratory testing
equipment
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Questions?
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.