Assisting with a Physical Examination and Health Assessment

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Did you know that employment of medical assistants is projected to grow 23 percent from 2018 to 2028, according to the U.S. Bureau of Labor Statistics? There is a great demand for medical assistants. Part of this exciting career involves preparing patients for physical examinations and health assessments in exam rooms.

Want to help patients stay in good health? Ready to become a medical assistant? The medical assistant will assist the physician with a patient’s physical examination and health assessment by preparing the room, preparing the patient, assisting with the physical examination, knowing the physical examination format, and assisting the patient after the physical examination is complete.

Room Preparation

The medical assistant is responsible for preparing the examination room, making sure the equipment and instruments are disinfected and sanitized, and the supplies are adequately stocked. The examination room should be clean, well lit, ventilated and at a comfortable temperature for the patient. After every physical examination and health assessment the medical assisting should disinfect the room and paper on the surfaces should be removed and replaced. The medical assistant must also make sure that the physical examination instruments are working properly and charged for the next patient examination.

Patient Preparation

Once the room is ready, the medical assistant will escort the patient to the examination room. It is the medical assistants goal to create a low-stress and comfortable atmosphere for patients. The medical assistant will record the patient’s history and check vital signs.

The medical assistant will then ask the patient to disrobe for the physical examination and health assessment and put on the examination gown. Once the patient is fully transitioned to the examination gown, the medical assistant will have the patient sit on the examination table and drape their legs for privacy. The medical assistant will then place the patient’s chart outside the examination room door and notify the physician that the patient is ready for the physical examination and health assessment.

Assisting with the Physical Examination

The medical assistant may assist the physician while performing the physical examination. The medical assistant will be responsible for handing the proper instruments and supplies to the physician. The medical assistant may also help the patient move into the appropriate position while adjusting the drape to expose the right part of the body for the physician to examine the patient.

Physical Examination Format

The physical examination and health assessment begins with the patient on the examination table with a drape sheet over the lap and covering the legs. The physician will examine the patient in an orderly and methodical sequence. First, viewing the patients head and neck. Then, examining the eyes and ears, nose and sinuses, mouth and throat, chest, breasts and abdomen, genitalia and rectum, and legs. Finally checking the patient’s reflexes.

Head and Neck – The patient’s skull, scalp, hair and face are inspected for size, shape and symmetry. The physician will look for any nodules, masses or local trauma. The trachea, lymph nodes and thyroid gland are examined for size and symmetry. Finally, the physician examines the carotid arteries to check for abnormal sounds caused by a blockage.

Eyes and Ears – The physician will inspect the fibrous tissue covering the eye for normal coloring. Then the pupils are inspected with a penlight to view their size and see if they react normally to light. The patient will follow the physician’s finger to examine proper eye movement. The ears are inspected for size, symmetry, lesions and nodules. The physician uses an otoscope to examine the interior of the ear for discoloration and fluids caused by infection. Auditory acuity is tested with the tuning fork or the audioscope.

Nose and Sinuses – the external nose is examined for abnormalities and the interior of the nose is examined using a nasal speculum and penlight. Each nostril is inspected for discharge, lesions or other signs of infection.

Mouth and Throat – the physician inspects the mucous membranes, gums, teeth, tongue, tonsils, and throat. The physician looks for any abnormalities including color, ulcerations and nodules.

Chest, Breasts & Abdomen – the physician looks for any obvious masses or swelling. With the stethoscope, the physician listens for any abnormal sounds in the lungs, heart and apical pulse while the patient takes deep breaths. The breasts of male and female patients will be examined for any abnormalities or masses. Then, the physician examines the abdomen for contour, symmetry and movement from the aorta. The physician will also use the stethoscope to listen to the bowel sounds. Finally, the physician will examine the abdomen organs for enlargement, masses, pain or tenderness.

Genitalia and Rectum – the male genitalia are inspected for lesions, swelling, masses and hair distribution. The scrotum is checked for testicular size, contour and consistency. The anus is inspected for lesions and hemorrhoids. The female genitalia and rectum are inspected for lesions, edema, cysts, discharge and hair distribution.

Legs – the legs are inspected for any abnormalities and the pulse is measured for extremity blood pressure. The legs are also inspected for varicose veins.

Reflexes – the physician uses the percussion hammer to test the patient’s reflexes by striking the biceps, triceps, patellar, Achilles and plantar tendons.

After the Physical Examination

The medical assistant will perform any follow-up treatments and procedures as ordered by the physician (i.e. flu shot administration). They will ask the patient to redress and wait for further instructions. The medical assistant will escort the patient to the front desk where they can schedule any follow-up appointments.

The medical assistant will want to dispose of any disposable supplies and equipment used during the physical examination and health assessment. from the exam room Then, the medical assistant will cover the examination table with clean paper and prepare the room for the next patient.

Ready to learn more about assisting the physician with a physical examination, exam room preparation and health assessment? Interested in becoming a medical assistant? Gwinnett Colleges & Institute offers medical assisting courses to gain essential skills and training. The core curriculum focuses on the medical assisting skills and training you will need to seek entry-level employment in physicians’ offices, clinics, hospitals, and other medical settings needing the services of associates trained in both front and back office medical assisting skills. These medical assisting courses will be the first step in starting a rewarding career.

Atlanta campuses – CLOSED Wednesday, January 17, 2018

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Faculty, Staff, and Students –

As you’re all likely aware, most of the metro-Atlanta area is experiencing inclement weather. Governor Deal has even issued a state of emergency for most of the metro-counties. Due to this, we are closing all Atlanta campuses tomorrow, Wednesday, January 17, 2018.

Students and faculty – We will review schedules for make-up days tomorrow and discuss options on Thursday.

Please note that if you read media coverage of Governor Deal’s state of emergency, people are discussing that a state of emergency allows for schools to not be required to makeup any missed days. We cannot attest to the accuracy of this statement at the primary level. However, in a post-secondary institution separate from the Georgia Board of Education, we are bound by a different set of policies. Makeup classes will be scheduled.

We hope everyone enjoys their day off. Stay warm and stay safe. We look forward to seeing you Thursday.

Massage Therapy Tools of the Trade

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According to the U.S. Bureau of Labor Statistics, employment of massage therapists is projected to grow 24 percent from 2016 to 2026, much faster than the average for all occupations. Continued growth in the demand for massage services will lead to new openings for massage therapists.

After completing a massage therapy diploma program, graduates may be interested in self-employment. Not only will self-employed massage therapist want to learn proper massage therapy techniques at a vocational college, but they will also want to learn about the tools and accessories that will make their massage therapy customers request repeat appointments. The massage therapy tools include the table and related accessories.

Massage Tables

Almost all of the massage tables that are sold are portable which are designed to fold in half and go with the massage therapist to off location appointments.  Make sure to purchase professional-grade equipment and tools for the clients’ comfort and safety.

The features of the massage table are important. Most massage tables will be configured differently by width, height, length, framing, padding and fabric. The massage table should suit the body of the massage therapist as they will be the ones using and carrying the massage table.

Massage Table Width – The width of the massage table will usually depend on the height of the massage therapist. A shorter massage therapist may want to buy a shorter width massage table as it is easier to carry. Having a wider table may cause the massage therapist to lose leverage as they may need to reach across the client’s body. However, any massage table too small will leave the client’s arms hanging of the sides and make them uncomfortable.

Massage Table Height – All massage tables have an adjustable height range. The optimal height of the massage table is determined by the height of the massage therapist, the type of massage, and the total mass of the client. A massage therapist should be able to touch the top of the massage table with a clinched fist and straight arm.

Massage Table Length – most massage tables are around 72 inches in length to accommodate a client that is over six feet table. For taller clients, the massage therapist can use bolsters under the knees to shorten the length of the client.

Massage Table Frame – most massage tables are made of wood or aluminum. Wood frames tend to be heavier than aluminum frames. An aluminum massage table will make transport easier.

Massage Table Padding – this is the part of the massage table that a client will remember. Selecting the right table padding is important and you must consider the density, thickness and durability of the padding.

  • Density – padding ranges from low, medium to high density. High-density foams typically have more memory. However, the higher density the foam, the heavier the massage table.
  • Thickness – thick padding is best for client comfort. Firm padding will also help the massage therapist regain energy when deep pressure is applied. Some massage tables have a single layer of foam and others multiple layers. The deeper the pressure, the thinner the foam should be to allow the massage therapist to focus on structure and movement. However, most massage therapist use multi-lawyer foam as it is more comfortable for the client.
  • Durability – when it comes to durability the massage therapist will want to consider what type of foam they are using and how many massages they tend to perform.

Massage Table Fabric – the most common fabric for massage tables is vinyl. Vinyl is long lasting and easy to clean. Keep the vinyl clean by wiping it down daily. Make sure to use a protective drape so the client’s body oils don’t come in contact with the vinyl massage table.

Massage Table Accessories

There are massage table tools and accessories that keep the client comfortable and safe. Accessories include the face cradle, arm shelf, side extensions, footrest, bolsters, linens and carrying case.

Face Cradle – The most common accessory is the face cradle that helps the client stay straight while lying prone. The face cradle will add up to 12 inches to the table’s length. The face cradle can be plastic, aluminum or metal. Metal and aluminum are more durable than plastic.

Arm Shelf – provides a place for arms to rest while the client is in the prone position. The different styles of arm shelf include a hinged shelf, a sling and a hanging shelf with adjustable straps.

Side Extensions – provides a place for arms to rest while the client is in the supine position.

Footrest – a padded platform that can increase the length of the massage table by up to 12 inches.

Bolsters – supportive devices that are used behind the neck, ankles and knees to offer the client increased relaxation. Bolsters come in a variety of shapes and sizes. Traditionally, bolsters are used under the ankles in prone position and the knees and neck in supine position.

Linens – the use of sheets, towels, and blankets can increase the comfort of the client and create an easier way to clean the massage table between clients. Massage table linens include a top and bottom sheet for the massage table, bolster covers, face rest cover, pillowcases, and arm shelf cover. For comfort and easy cleaning, many massage therapists use flannel.

Carrying Case – helps protect the fabric on the massage table while in transit. The carrying case also has a padded handle and strap for the massage therapist to easily carry from place to place.

Massage Chairs

A massage chair can be moved easier and takes up less space than a massage table. However, the cost of a massage chair is almost the same price as a massage table. The massage chair should be lightweight and easy to setup or breakdown. It should also be sturdy, so the client feels safe and comfortable.

Interested in learning more about massage therapy tools and how to offer a comfortable experience for your clients? Ready to become a massage therapist? Upon graduation, Massage Therapy Program students will receive diplomas and be qualified to seek entry-level positions as clinical, medical, or deep tissue massage therapists in wellness clinics and centers, spa environments including resorts and franchises, and self-employment.

Contact us to learn more about how you can become a massage therapist today.

 

The Basics of Clinical Coding: CPT and ICD-10-CM

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The medical billing and coding professional will need to become very familiar with clinical coding using the basic ICD-10-CM & CPT coding system as this will be used for clinical coding on patient charting and medical insurance billing. Clinical coding will identify procedures and conditions that the physician will need to report on based on patient diagnosis. The ICD-10-CM is broken into the Alphabetic Index and Tabular Index that work together to create clinical coding used by the medical billing and coding assistant. As a medical biller and coding professional, you will need to know how to locate a code in the ICD-10-CM & CPT. They will also need to understand the basic definition of a medical diagnosis and medical procedure.

What is Clinical Coding?

Coding is the transformation of verbal descriptions into numbers. Assigning numeric or alphanumeric codes for clinical procedures and conditions. A clinical code can be part of a classification system that groups similar diseases and procedures together, helping to organize related medical information. The classification system used in the United States is the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). The official version of the ICD-10-CM guidelines are approved by the Cooperating Parties for the ICD-10-CM including members from the American Hospital Association (AMA), the American Health Information Management Association (AHMA), Centers for Medicare and Medicaid Services (CMS) and National Center for Health Statistics (NCHS). The CPT & HCPCS coding systems are maintained by with the Centers for Medicare & Medicaid Services.

The clinical coding conventions for ICD-10-CM address the structure and format of the coding system, including an Alphabetic Index, Tabular List and the rules and instructions that a medical billing and coding assistant must follow. Clinical codes consist of three to seven basic characters. The first three characters identify the category of the clinical code, the next three characters identify the etiology, anatomic site and the severity, and the seventh character can be used to add a specificity to the clinical code.

Abbreviations are used in ICD-10-CM including “not elsewhere classifiable”(NEC) and “not otherwise specified”(NOS). Punctuation is used in the coding system including brackets, parentheses and colons. Square brackets are a punctuation mark used in the Tabular List to enclose synonyms, abbreviations, alternative wording or explanatory phrases. Slanted brackets are used in the Alphabetic Index to identify manifestation codes. The manifestation code represents a secondary condition that was caused by the primary condition. Parentheses are a punctuation mark that encloses supplementary words or explanatory information not present in the statement of the diagnosis. The colon is a punctuation term that is used in the Tabular List after an incomplete term that needs additional terms to assign a specific clinical code.

The Alphabetic Index

The Alphabetic Index is divided into two parts 1) the index to diseases and injury 2) index to external causes of injury. It is designed to allow medical billing and coding assistants to look up medical terms and connect them with the appropriate ICD codes.

The Tabular List

The Tabular List is a numerical listing of all codes. It is divided into 21 chapters and focus on the body or organ system and certain infectious and parasitic diseases. The first character of an ICD-10-CM code is always an alphabetic letter. All letters of the alphabet are used except for the letter U that is reserved by the World Health Organization (WHO) for new diseases and for bacterial agents resistant to antibiotics.

Locating a Code in the ICD-10-CM

The medical billing and coding professional must use both the Alphabetic Index and Tabular List to assign a clinical code. The medical billing and coder will identify the main term and any sub-terms in the Alphabetic Index. The clinical code in the Alphabetic Index is then verified by the Tabular List. Diagnosis codes are to be reported with the highest number of characters available.

What is a Medical Diagnosis?

A diagnosis is a word or phrase used by a medical professional to identify a disease or condition a patient suffers from, for which the patient needs medical care. A diagnosis is identified after a physical exam of the patient. Clinical CPT codes that describe signs and symptoms may be used if that is the only thing the physician knows about the patient’s condition. If the patient is suffering from an acute or chronic condition, the medical billing and coding professional must identify, in the Alphabetic Index, if there are separate entries at the same indentation level.

What is a Medical Procedure?

A medical procedure is a medical surgery or therapeutic procedure on or within the patient’s body that is intended to achieve a result for the patient.

Conclusion

Familiarity with using the ICD-10-CM & CPT coding system is an important part of a medical billing and coding professional’s job.  The ICD-10-CM coding system can be learned by attending a vocational school which offers courses on this topic.

Are you interested in learning more about basic clinical coding, CPT codes and ICD-10-CM coding systems? Gwinnett Colleges & Institute’s Medical Billing and Coding programs will provide you with the opportunity to learn insurance coding and processing, medical administrative procedures, and the regulatory requirements in the healthcare delivery system.  School externships provide the opportunity to apply the medical billing and coding skills learned in the classroom in actual medical settings. Gwinnett Colleges & Institute offers medical billing & coding courses to gain essential skills and training to achieve entry-level positions in this career field. These medical billing & coding courses will be the first step in starting a rewarding career.

Contact us to learn more about how you can become a medical billing and coding assistant today.

 

The Basics of Computer Hardware

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In 1975, the personal computer revolution started creating jobs for computer technicians. 1985 saw the great expansion of the personal computer with the first shipment of Windows for PCs. The next explosion in personal computing came in 1995 with the introduction of the World Wide Web to the public. The computer information systems field continues to grow to this day. According to the U.S. Bureau of Labor Statistics, employment of computer support specialists is projected to grow 10 percent from 2016 to 2026.

In 2016, 269 million personal computers were sold in the US, Wikipedia. The number of tablets is forecasted to reach 185 million by 2020. That equates to, at a minimum, one computer or tablet per employee in most every company in the US. Who is going to maintain all of these computers and tablets? Interested in learning more about computer hardware as a computer technician? The following blog article focuses on the personal computer, microprocessor, storage devices, and peripherals.

Personal Computer System

A personal computer (PC) is a multi-purpose computer that includes peripherals, memory storage, hard disk drive, sound card, modem and/or network card.

System Unit – holds the computer’s main circuit board, microprocessor, memory, power supply and storage device.

Hard Disk Drive – the main storage on a personal computer system.

Optical Drive – a storage device that works with CDs and DVDs.

External Storage – includes external hard disks, USB flash drives and memory cards.

Keyboard – the primary input device, typically a QWERTY interface with 10-key accompaniment.

Mouse – an input device designed to manipulate on-screen graphical objects and controls.

Printer – an output device that produces computer-generated text or graphical images on paper.

Sound System – output of digital music, recorded speech and other sound effects. The personal computer system uses a sound card that sends signals to the speakers.

Display System – includes a graphics card that converts raw digital data into images to display on the monitor. Monitors use display technologies including LCDs and LEDs.

Network and Internet Access – built-in circuitry for wired or wireless connections to a computer network. Most internet connections require a modem.

A personal computer system can be upgraded to make it more powerful. The computer’s processor, internal hard disk drive, graphics card, and CD/DVD drive can be replaced. Memory, external hard drives, a second display screen and USB ports can be added.

Microprocessor

A microprocessor or CPU is an integrated circuit designed to process instructions. The computer can have a single microprocessor or multi-core processor. More cores means faster performance.

Random Access Memory (RAM) – RAM is a temporary holding area for data, application program instructions and the operating system.

Read-Only Memory (ROM) – a type of memory that holds the computer’s startup routine.

EEPROM – Electrically Erasable Programmable Read-Only Memory; stores the basic hardware settings without the need for power to the computer.

Storage Devices

The basic components of a data storage system include a storage medium and storage device. The storage medium is the disk, CD or DVD that contains data. The storage device is the mechanical apparatus that records and retrieves data from a storage medium.

Peripherals

Input devices consist of keyboards, touch-sensitive screens, a mouse, scanners, digital cameras, and a microphone. Output devices include printers, monitor and digital cameras.

Pointing Device – use of a mouse, trackball, or joystick to allow the user to manipulate an on-screen pointer and screen-based graphical controls.

Display Devices – displays text and images. Image quality depends on screen size, dot pitch, width of viewing angle, response rate, resolution and color depth.

  • Dot pitch – a measure of image clarity, a smaller dot pitch translates into a crisper image.
  • Width of viewing angle – indicates how far to the side a user can still clearly see the screen image.
  • Response rate – the time it takes for one pixel to change from black to white and then back to black.
  • Resolution – the number of horizontal and vertical pixels that are displayed on the screen.
  • Color depth – the number of colors a monitor can display.

Printing Devices – printers typically use either an ink jet or laser technology. Printers differ in resolution, speed, duty cycle, operating costs, two-sided printing and memory.

Does learning about Computer Hardware interest you? Are you looking for a rewarding career at a as a help desk specialist or computer technician? The Computer Information Systems/Business Administration diploma program, at Gwinnett College’s Lilburn, GA campus, is designed to train the college graduate to seek an entry-level career in office management utilizing accounting and computer information systems.

Computer Information Systems/Business Administration graduates from this program can also transfer their school credits directly into the Associate of Science Degree in Business, Computer Information concentration, program. They will need to complete four additional courses to obtain their associate degree.

Contact us today to learn more about becoming a computer help desk specialist or computer technician.

 

Computer Information Systems: Big Data and the Internet of Things

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Businesses spend trillions of dollars every year on computing and information systems. Banking & Securities companies spend the most on IT followed closely by manufacturing and natural resources, government and communications media services according to Gartner. Companies are looking for data solutions to get a competitive advantage in their industry. This surge is fueled by information management, big data and analytics tools. What does this mean for you? It means an increased need for computer technicians and help desk specialist to keep the infrastructure running smoothly.

What is Big Data?

Big data involves managing data sets so large and complex that traditional processing application software is inadequate to capture, curate, manage, and process the data within a reasonable amount of time. Big data can be used for predictive and user behavior analytics. Understanding the trends in a company’s industry can give them a competitive advantage and allow them to get first to market with any idea or product.

The challenges of big data can be measured by increasing amounts of data, the speed of data, and the range of data types and sources. Big data can be measured by the five Vs; characteristics that include volume, variety, velocity, variability and veracity.

  • Volume – the total amount of stored data. This can range from terabytes to exabytes of data.
  • Variety – the range of data types and sources.
  • Velocity – the speed that the data is generated and processed.
  • Variability – the lack of consistency among data gathered and processed.
  • Veracity – data quality for accurate analysis

One growing source for big data is the Internet of Things.

What is the Internet of Things (IoT)?

The Internet of Things is the network of devices, vehicles, home appliances and any item with network connectivity allowing it to exchange data. The Internet of Things is all around us now. From your cell phone to the refrigerator in your kitchen. Even toasters are connected to the Internet. Big data and the Internet of Things work together hand in hand. Data can be extracted from the Internet of Things to understand buyer behavior, track user trends and create a mapping of devices interconnectivity. This abundance of information can help businesses make better decisions. Add demographic, geographic and psychographic elements to the data and it offers finer detail into the buying behaviors and consumer trends of the marketplace.

Why Do Connected Devices Need to Share Data?

The short answer is, it makes them perform better. Maybe you don’t need your toaster talking to your dishwasher but having self-driving cars talk to each other makes a lot of sense. What about your refrigerator telling your cell phone to buy more milk? Also, smart sensors can help cut down on waste. Nest thermometers can manage the heating and air conditioning in the home, so energy is not wasted. Dryers can sense when the clothes are dry instead of using a timer that may waste energy. With sensors, our consumer products can increase efficiency, cut down on waste and offer data to better manage resources.

Techniques in Big Data and Information Management

There are many different techniques to analyze big data, they include A/B testing, machine learning, natural language processing and data mining.

A/B Testing – a controlled experiment with two variants. Both variants are measured until a statistically significant finding can be made. Then a new variant is introduced to compete against the winner. The goal is continuous improvement.

Machine Learning – the ability of computers to learn without being explicitly programmed. Machine learning explores the construction of algorithms that can learn from and make predictions on data. Machine learning makes data-driven predictions rather than strictly following program instructions.

Natural Language Processing – the ability of a computer program to understand human language as it is spoken.

Data Mining – the process of discovering patterns in large data sets using understandable structure for later use.

Technologies in Big Data

There are many different technologies used to manage and analyze big data, they include business intelligence, cloud computing, predictive analytics, stream processing, in-memory data fabric and distributed file systems.

Business Intelligence – strategies and technologies used for the data analysis of business information. One of the technologies used for business intelligence analysis is data warehousing, A data warehouse is a relational database used for reporting and data analysis and typically includes historical transactional data.

Cloud Computing – the delivery of computing services over the Internet using remote servers, storage, databases, networking, software and analytics.

Predictive Analytics – software or hardware that allows a company to discover, evaluate, optimize and deploy predictive models by analyzing big data sources.

Stream Processing – analyzes and performs actions on real-time data through the use of continuous queries.

In-Memory Data Fabric – the processing of large data sets by distributing the data across the memory of a distributed computer system.

Distributed File Systems – a computer network that stores data on more than one node for redundancy and performance.

Final Thoughts

An ability to manage large sets of data to make forward looking decisions is about more than computers. Any business analyst will need to utilize information management, big data and the Internet of Things to make their processes, products and services better for their customers. As a computer technician, you can use this to your advantage. Get ready to start a career with growth potential and an ever-sharper learning curve.

Does learning about Big Data and the Internet of Things interest you? Are you looking for a rewarding career at a company that provides computer support to its employees? The Computer Information Systems/Business Administration diploma program, at Gwinnett College’s Lilburn, GA campus, is designed to train the college graduate to seek an entry-level career in office management utilizing accounting and computer information systems.

Computer Information Systems/Business Administration graduates from this program can also transfer their school credits directly into the Associate of Science Degree in Business, Computer Information concentration, program. They will need to complete four additional courses to obtain their associate degree.

Contact us today to learn more about becoming a computer help desk specialist or computer technician.

 

Medical Assistant: Medical Specialty Choices After Graduation

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Ready to become a medical assistant but wonder what options you have after graduating from a medical assistant program? Entry-level medical assistants can work towards unique specialties. Regardless of which specialty a medical assistant works in they will be responsible for administrative and clerical duties including answering phones, scheduling appointments, greeting patients, helping to take vital signs, processing billing and insurance claims, filing paperwork both paper and electronic and entering patient information into computer databases.

Specialty Options for Medical Assistants

As a medical assistant, there are many specialties to choose from depending on which type of doctor or clinic you work for. The medical assistant can work in immunology, chiropractic, dermatology, emergency medicine, family medicine, obstetrics, ophthalmology, osteopathy, otolaryngology, pediatrics, podiatry, pathology, plastic surgery and radiology. The following is an explanation of the medical specialties and how the medical assistant may assist.

Allergy and Immunology – the medical assistant will assist in the treatment of adults and children with allergies and problems of the immune system. They will work with allergists and immunologists that diagnose, manage and treat allergic and autoimmune disease.

Chiropractic – the technique of spinal manipulation. The medical assistant will greet and escort patients to exam rooms. They will assist the chiropractic practice by perform administrative tasks including answering phones, processing insurance claims and filing of patient information.

Dermatology – the medical assistant will assist a dermatologist that specializes in the skin. The dermatologist diagnoses skin disease and may perform minor surgery, with the help of a medical assistant.

Emergency Medicine – for a faster paced environment, the medical assistant can work in emergency medicine, typically in a hospital. Emergency medicine focuses on treating acute illnesses and injuries that need immediate care. The medical assistant will support the nurses and emergency doctors with patient management, information gathering, filing, and support of colleagues with clerical duties.

Family Medicine – the medical assistant will work alongside doctors treating adults and children for routine care. They will work to educate patients in how to stay healthy and treat the total health of the individual. The medical assistant in a family practice will do many administrative and clerical tasks in addition to patient education and management.

Obstetrics – specialty that involves the care of patients during pregnancy and delivery. The medical assistant assists by checking in patients, reading vital signs, and educating the patient and their family on the procedure.

Ophthalmology – specializes in the care of a patient’s eyes. The medical assistant helps the ophthalmologist manage disease and conditions of the eye. They will also help educate the patient that is getting tested for glasses, undergoing surgery, laser correction or the proper use of contact lenses.

Osteopathy – a mix between scientific and holistic medicine that focuses on healing the entire person rather than a specific disease or condition.

Otolaryngology – specialty that focuses on the care of the ear, nose, throat, head and neck. The medical assistant will assist in medical examination, minor surgery and many different administrative tasks that are needed in an otolaryngologist’s office.

Pediatrics – this specialty involves the care of children from birth to adolescence. Many medical assistants will choose pediatrics because they like working with children.

Podiatry – treatment of the disorders of the feet and ankles. The medical assistant can help those with diabetes, the elderly and others that require specialized foot care, while working in a podiatry practice.

Pathology – examines cells, tissues and specimens to determine whether a structure in the body is normal and attempt to determine the cause of a disease. Medical assistants may assist the pathologist in preparing work spaces, keeping workstations disinfected and helping with filing of patient information.

Plastic Surgery – the surgical and non-surgical treatment of physical defects in the human body. The medical assistant will work alongside the plastic surgeon to keep the practice running smoothly both during procedures and with clerical responsibilities.

Radiology – specialty involving the use of x-ray, computed tomography (CT) scan, and magnetic resonance imaging (MRI). Medical assistants will assist will equipment upkeep and cleaning for radiologist to get accurate images to better treat patients.

Does one or more of these specialties interest you? Interested in becoming a medical assistant? Gwinnett Colleges & Institute offers medical assisting courses to gain essential skills and training. The core curriculum focuses on the medical assisting skills and training you will need to seek entry-level employment in physicians’ offices, clinics, hospitals, and other medical settings needing the services of associates trained in both front and back office medical assisting skills. These medical assisting courses will be the first step in starting a rewarding career.

5 Ways for Medical Assistants to Improve their Documentation Skills

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Interested in learning more about how medical assistants document patient information in charts and records? There’s a saying in healthcare, and specifically around documentation of records, that if it isn’t written down and recorded, it didn’t happen. Maintaining accurate records is vital so there is a clear account of a case history. This is also crucial for the next person looking at those documents and charts after you to know what has been done. Medical assistants can make some common mistakes during documentation. However, there are 5 ways for medical assistants to improve their documentation skills, they include being accurate and succinct, not being judgmental, using only appropriate abbreviations, clearly marking mistakes, and recording conversations.

Be Accurate and Succinct

Good documentation is an art. It is vital to be specific and keep to the point. Recording essential detail such as vital signs, pain control and a change in condition are a must. Be descriptive and set out what happened and what was done about it, particularly when escalating a problem. If you take blood or another sample from a patient, record the time and date it was taken. Repeated procedures are a common mistake made by medical assistants that don’t follow proper documentation. This stops a repeat of the same test and alerts the next person looking after the patient to look for the results. It also means that the patient or insurance company will get billed properly. The medical assistant will want to record the correct date and time in records, to not make these common mistakes.

Don’t be Judgmental

When documenting records, the medical assistant should be factual without making assumptions. A common mistake medical assistants are guilty of is writing opinions about a patient like “difficult patient.” This can get them into trouble not only with their manager but also the patient and their family. Patients can request to see their notes and finding something unpleasant about them is not professional, especially if their behavior is a symptom of their illness.

Use Appropriate Abbreviations

The healthcare sector tends to use abbreviations, but they don’t always have the same meaning in every organization? Take BID as an example. On a prescription, it can mean bis in die or twice daily in Latin. It can also stand for brought in dead. The medical assistant should always write something in full unless there is an accepted form of abbreviations used in the organization. Remember that what is a commonly used abbreviation in one organization may have an entirely different meaning in another.

Clearly Mark Mistakes

Sometimes medical assistant writes something down and realizes they made a mistake, or there’s a spelling error they need to correct. If the medical assistant is typing, it is easy to delete and start again. If they are using a handwritten document, they will need to put a line through the mistake, initial it and start again. They should not use Tippex or stick paper over the mistake. Removing notes looks suspicious in medical records. Also, the medical assistant should try to write in blue or black pen, so the records can easily be photocopied.

Making Mistakes as a Medical Assistant

After a successful career as a student, it’s tough for a medical assistant to suffer their first on-the-job failure. Making an error, especially if it’s a serious one, can cause a crisis of confidence. If it continues, a medical assistant may become tentative and second-guess their decisions, making their job stressful and in some cases, impossible.

As a trait, confidence is hard to quantify, but as a skill, it’s easy to cultivate by remembering that no one is perfect, and that failure can sometimes be the best teacher. It takes confidence to become a medical assistant, nurture it by setting realistic goals and allowing room for mistakes.

Record Conversations

If the medical assistant has a conversation with a member of a patient’s family or the patient, it is important to write down what was said, particularly if there were instructions or concerns about care. This means that subsequent staff can see what has been communicated. If the medical assistant gives telephone advice, they should make sure to document this too, as well as noting the date and time of the call.

Don’t Work Beyond A Skill or Certification Level

A medical assistant has strict guidelines and there are laws that they must abide by. A common mistake that a medical assistant may be guilty of is documenting something they are not certified in or trained properly on. This can cause confusion and errors in documentation. If the medical assistant is unsure about a term or abbreviation, they should ask for clarification.

Double Check Others Documentation

It is important to double check other medical assistant’s documentation regularly, especially those entry-level medical assistants. They can make common mistakes in documentation, and by catching them before they are submitted as a claim, a senior medical assistant can help avoid the hassle and possible patient complications.

Final Thoughts

Documenting care and keeping accurate records is a vital component of the work of a medical assistant. A medical assistant may make a few common mistakes. But, by getting it right the medical assistant will be helping colleagues and ensuring the patient’s needs are being met.

Does documentation in medical assisting interest you? Are you interested in becoming a medical assistant? Gwinnett Colleges & Institute offers medical assisting courses to gain essential skills and training. The core curriculum focuses on the medical assisting skills and training you will need to seek entry-level employment in physicians’ offices, clinics, hospitals, and other medical settings needing the services of associates trained in both front and back office medical assisting skills. These medical assisting courses will be the first step to starting a rewarding career.