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1. Medical assistant
1.1 The professional medical assistant
1.2 Standards of care
1.3 Achieving a credential
1.4 The history of medical assisting
1.5 Teamwork and the patient-centered medical home
2. Electronic records
3. Medical terminology and anatomy
4. The fundamentals of infection control
5. Introduction to vital signs
6. The patient interview and history
7. The physical examination
8. Appointment scheduling
9. Insurance billing
10. Diagnostic coding and the ICD-10-CM System
11. Procedural coding
12. Medical billing and reimbursement essentials
13. Assisting with medical specialties
14. Assisting with the musculoskeletal system
15. Assisting with the cardiovascular system
16. Assisting with the respiratory system
17. Assisting with the nervous system
18. Anatomy and physiology of the urinary system
19. Assisting in obstetrics and gynecology
20. Assisting in endocrinology
21. Assisting in ophthalmology & otolaryngology
22. Assisting in gastroenterology
23. Assisting in the immune & lymphatic systems
24. Assisting in pediatrics: the developmental stages and care
25. The medical assistant’s role in caring for the older patient
26. The role of the medical assistant in physical therapy examination and assessment
27. Preparing for minor surgery: room, solutions, and supplies
28. Introduction to the clinical laboratory
29. Urinalysis
30. Blood collection
31. Analysis of blood
32. Electrocardiography and heart structure
33. The principles of pharmacology
34. Essential calculations and measurement systems
35. Solid, liquid, & solutions medication doses
36. Administering medications
37. Metabolism and core nutrient roles
38. Medical emergencies in the healthcare setting
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1.4 The history of medical assisting
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1. Medical assistant
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The history of medical assisting

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The history of medical assisting

As physicians made the switch from going to patients’ homes for treatment to having the patient come to their office, some physicians hired nurses to help in their practices. Gradually, the administrative part of running a practice became increasingly complicated and time consuming, and physicians realized that they needed an assistant with both administrative and clinical training. Nurses were likely to have training only in clinical skills; therefore, many physicians began training individuals-medical assistants-to assist with all the office duties.

The first medical assistants started working in individual physicians’ offices with on-the-job training to help out when an extra pair of hands was needed. Today, medical assisting is one of the most respected allied health fields in the industry, and training is readily available through community colleges, junior colleges, and private educational institutions throughout the United States.

Allied health professionals

In addition to doctors, nurse practitioners, and physician assistants, the healthcare team includes allied health professionals. The definition of an allied health professional can vary, but it loosely refers to those who can act only under the authority of a licensed medical practitioner.

Who are allied health professionals?

Allied health professionals include respiratory therapists, radiation therapists, occupational therapists, physical therapists, technologists of various types, dental hygienists, medical assistants, phlebotomists, pharmacy technicians, therapeutic services and provide care.

The allied health professions fall into two categories, technicians (assistants) and therapists. This includes, among others, physical therapy assistants, and medical assistants.

The educational process for nurses and therapists can be more intensive. These positions require a state-issued license and an advanced degree, showing that the individual is trained to evaluate patients, diagnose conditions, develop treatment plans, and understand the rationale behind various treatments.

Allied health professionals as part of the healthcare team

Allied health professionals typically work as part of a healthcare team, which is what will be done by you as a medical assistant. As a new medical assistant, you will be part of an ever-growing group of allied health professionals who provide a variety of services to patients in a variety of settings in today’s healthcare system.

60% of the healthcare workforce are allied health professionals. The term allied health is used to identify a cluster of health professionals encompassing as many as 200 careers. In the United States, about 5 million allied health professionals work in more than 80 different professions; they represent approximately 60% of all healthcare workers.

Types of healthcare facilities

There are several different professions involved when providing healthcare. We also need to consider where that healthcare is provided. In this next section we will look at the various healthcare facilities.

Hospitals

Hospitals are classified according to the care and services they provide to patients and by the type of ownership. There are three levels of hospitalized care:

Levels of hospitalized care

  • Primary level of care

    • Smaller city or community hospitals
    • Usually serve as the first level of contract between the community members and the hospital setting
  • Secondary level of care

    • Both PCP’s and specialists provide care
    • Larger municipal or district hospitals that provide a wider variety of specialty care and departments
  • Tertiary level of care

    • Referral system for primary or secondary care facilities
    • Provide care for complicated cases and trauma
    • Medical centers, regional and specialty hospitals

Hospital ownership

Private hospitals are run by a corporation or other organization and usually are designed to produce a profit for the owners or stockholders.

Nonprofit hospitals exist to serve the community in which they are located and are normally run by a board of directors. The term nonprofit sometimes is misleading because “profit” is different from “making money”. A nonprofit hospital or organization may make money in a campaign or fundraiser, but all of the money is returned to the organization. Nonprofit hospitals and organizations must follow strict guidelines in the area of finance and must account to the government for the money brought in and the purposes for which it is used.

Hospital systems and integrated delivery systems

A hospital system is a group of facilities that are affiliated and work toward a common goal. Hospital systems may include a hospital and cancer center in a small community or may consist of a group of separate hospitals in a specific geographic region.

An integrated delivery system (IDS) is a network of defined population and is willing to be held clinically and fiscally accountable for the clinical outcomes and health status of the population served. Services provided by an IDS can include a fully equipped community or tertiary hospital, home healthcare, and hospice services, primary and specialty outpatient care and surgery, social services, rehabilitation, preventive care, health education and financing, and community provider offices. An IDS can also be a training location for healthcare professionals, students, including physicians, nurses, and allied health professionals.

Accreditation and quality standards

Accreditation is considered the highest form of recognition for the quality of care a facility or organization provides.

It indicates to the public that the facility is concerned with providing high-quality care, and it also provides professional liability insurance benefits, and plays a role in regulatory agency licensure and certification efforts.

Hospitals and other healthcare facilities are accredited by the Joint Commission, an organization that promotes and evaluates the quality of care in healthcare facilities. Standards or indicators have been developed to help determine when patients are receiving high-quality care.

The term quality refers to much more than whether the patient liked the food served or had to wait to have a procedure or test performed.

Categories of compliance include the following:

  • Assessment and care of patients
  • Use of medication
  • Plant, technology, and safety management
  • Orientation, education, and training of staff
  • Medical staff qualifications
  • Patient’s rights

National Patient Safety Goals

Accreditation by the Joint Commission is required to obtain reimbursement from Medicare, managed care organizations, and insurance companies.

Besides accrediting healthcare facilities, the Joint Commission carefully evaluates patient safety. It has established the National Patient Safety Goals, which must be addressed by member facilities.

The 2021 safety goals for ambulatory organizations took effect January 1, 2021, and include the following:

  • Identifying patients correctly
  • Using medicines safely
  • Preventing infection
  • Prevent mistakes in surgery

Ambulatory care

Ambulatory care centers include a wide range of facilities that offer healthcare services to patients who seek outpatient health services. Physician’s offices, group practices, and multispecialty group practices are common types of ambulatory care facilities, and medical assistants can be employed in all of these practices.

Group practices may involve a single specialty, such as pediatrics or may be multispecialty. A multispecialty practice might consist of an internal medicine physician, an oncologist, a cardiologist, and an endocrinologist.

The providers of the practice refer patients to each other when indicated. This is therefore more convenient for the patients and tends to be more profitable for the members of the practice.

Sidenote
Important!

A patient seeing a provider for the first time is considered to be a New patient, whereas a patient who has seen the provider on previous occasions is known as an established patient.

Most providers charge new patients more than established patients due to the extent of the physical examination, the levels of decision-making, and the complexity of the medical history. New patient’s medical history may require more time.

Specialized ambulatory care facilities

Occupational health centers are committed to helping patients return to work and productive activity. Often, physical therapy is used in conjunction with rehabilitation services to assist the patient in regaining as much of his or her previous level of abilities.

Pain management centers can help patients deal with discomfort associated with their condition.

Sleep centers diagnose and treat patients with sleep conditions.

Urgent or emergency care centers provide patients with an alternative to hospital emergency departments (EDs) and are often open when traditional providers’ offices may be closed.

Ambulatory surgical centers

Surgery has become more convenient because of the number of ambulatory surgical centers that exist today. Many insurance companies now prefer day surgery because it is more cost-effective.

A wide variety of outpatient surgical facilities are available, offering procedures in ophthalmology, plastic surgery, and gastrointestinal concerns, including colonoscopies and endoscopies.

Additional ambulatory care facilities

Dialysis centers offer services to patients with severe kidney disorders, and many of the larger cities across the country have cancer centers for patients needing treatment by an oncologist.

Other types of ambulatory care facilities are centers that provide magnetic resonance imaging (MRI), student health clinics, dental clinics, community health centers, and women’s health centers.

Other healthcare facilities

Several other healthcare facilities deserve attention in the broad overview of a healthcare industry.

Laboratories

Laboratories offer testing services for patients referred by providers.

The enactment of CLIA in 1967 and its amendment in 1988 established that the only laboratory tests that can be performed in a physician’s office lab are those designated as CLIA (Clinical Laboratory Improvement Amendments) waived.

You will learn how to perform a variety of CLIA-waived tests in your medical assistant program.

Smaller or independent practices typically have to send non-CLIA-waived tests to an outside diagnostic facility.

Tests that can be performed in a physician’s office are known as point-of-care testing (POCT).

Home healthcare and hospice care

Home health agencies or hospital-affiliated home healthcare organizations provide crucial services to patients who may require medical follow-up but are not in a hospital setting.

Home healthcare includes therapy services, administration of and assistance with medications, wound care, and other services so that the patient may remain at home, yet still obtain consistent medical attention.

Hospice care is a type of home health service that provides medical care and support for patients facing end-of-life issues and their families.

The goal of hospice is to provide peace, comfort, and dignity while controlling pain and promoting the best possible quality of life for the patient.

Some communities have inpatient hospice services available either in a special unity in a hospital or in an independent hospice center.

The history of medical assisting

  • Originated from need for both administrative and clinical support in physician offices
  • Early medical assistants trained on the job; now formal education widely available
  • Medical assisting is a respected allied health profession

Allied health professionals

  • Work under authority of licensed medical practitioners
  • Include a broad range of roles beyond doctors and nurses

Who are allied health professionals?

  • Examples: respiratory therapists, technologists, dental hygienists, medical assistants, pharmacy technicians
  • Two main categories: technicians (assistants) and therapists
  • Therapists and nurses require state licensure and advanced degrees

Allied health professionals as part of the healthcare team

  • Make up about 60% of healthcare workforce in the U.S.
  • Over 5 million allied health professionals in 80+ professions
  • Provide diverse services in various healthcare settings

Types of healthcare facilities

  • Healthcare delivered in multiple settings, not just hospitals

Hospitals

  • Classified by care level: primary (community), secondary (specialty), tertiary (referral/complex cases)
  • Ownership types: private (for-profit), nonprofit (community-focused)
  • Hospital systems: groups of affiliated facilities; IDS (Integrated Delivery System) offers comprehensive care and training
  • Accreditation by Joint Commission required for reimbursement; focuses on quality and patient safety
    • Key compliance areas: patient care, medication use, safety, staff training, patient rights
    • National Patient Safety Goals: patient identification, safe medication use, infection prevention, surgical safety

Ambulatory Care

  • Outpatient services: physician offices, group/multispecialty practices, urgent care, ambulatory surgical centers
  • New vs. established patients: new patients require more extensive evaluation
  • Specialized centers: occupational health, pain management, sleep, dialysis, cancer, MRI, student health, dental, community health, women’s health
  • Ambulatory surgery preferred for cost-effectiveness

Other healthcare facilities

  • Laboratories: perform CLIA-waived and point-of-care tests; non-waived tests sent to external labs
  • Home health agencies: provide medical care at home, including therapy, medication, wound care
  • Hospice care: supports end-of-life patients and families, focusing on comfort and quality of life
    • Available as home service or in specialized inpatient units

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The history of medical assisting

The history of medical assisting

As physicians made the switch from going to patients’ homes for treatment to having the patient come to their office, some physicians hired nurses to help in their practices. Gradually, the administrative part of running a practice became increasingly complicated and time consuming, and physicians realized that they needed an assistant with both administrative and clinical training. Nurses were likely to have training only in clinical skills; therefore, many physicians began training individuals-medical assistants-to assist with all the office duties.

The first medical assistants started working in individual physicians’ offices with on-the-job training to help out when an extra pair of hands was needed. Today, medical assisting is one of the most respected allied health fields in the industry, and training is readily available through community colleges, junior colleges, and private educational institutions throughout the United States.

Allied health professionals

In addition to doctors, nurse practitioners, and physician assistants, the healthcare team includes allied health professionals. The definition of an allied health professional can vary, but it loosely refers to those who can act only under the authority of a licensed medical practitioner.

Who are allied health professionals?

Allied health professionals include respiratory therapists, radiation therapists, occupational therapists, physical therapists, technologists of various types, dental hygienists, medical assistants, phlebotomists, pharmacy technicians, therapeutic services and provide care.

The allied health professions fall into two categories, technicians (assistants) and therapists. This includes, among others, physical therapy assistants, and medical assistants.

The educational process for nurses and therapists can be more intensive. These positions require a state-issued license and an advanced degree, showing that the individual is trained to evaluate patients, diagnose conditions, develop treatment plans, and understand the rationale behind various treatments.

Allied health professionals as part of the healthcare team

Allied health professionals typically work as part of a healthcare team, which is what will be done by you as a medical assistant. As a new medical assistant, you will be part of an ever-growing group of allied health professionals who provide a variety of services to patients in a variety of settings in today’s healthcare system.

60% of the healthcare workforce are allied health professionals. The term allied health is used to identify a cluster of health professionals encompassing as many as 200 careers. In the United States, about 5 million allied health professionals work in more than 80 different professions; they represent approximately 60% of all healthcare workers.

Types of healthcare facilities

There are several different professions involved when providing healthcare. We also need to consider where that healthcare is provided. In this next section we will look at the various healthcare facilities.

Hospitals

Hospitals are classified according to the care and services they provide to patients and by the type of ownership. There are three levels of hospitalized care:

Levels of hospitalized care

  • Primary level of care

    • Smaller city or community hospitals
    • Usually serve as the first level of contract between the community members and the hospital setting
  • Secondary level of care

    • Both PCP’s and specialists provide care
    • Larger municipal or district hospitals that provide a wider variety of specialty care and departments
  • Tertiary level of care

    • Referral system for primary or secondary care facilities
    • Provide care for complicated cases and trauma
    • Medical centers, regional and specialty hospitals

Hospital ownership

Private hospitals are run by a corporation or other organization and usually are designed to produce a profit for the owners or stockholders.

Nonprofit hospitals exist to serve the community in which they are located and are normally run by a board of directors. The term nonprofit sometimes is misleading because “profit” is different from “making money”. A nonprofit hospital or organization may make money in a campaign or fundraiser, but all of the money is returned to the organization. Nonprofit hospitals and organizations must follow strict guidelines in the area of finance and must account to the government for the money brought in and the purposes for which it is used.

Hospital systems and integrated delivery systems

A hospital system is a group of facilities that are affiliated and work toward a common goal. Hospital systems may include a hospital and cancer center in a small community or may consist of a group of separate hospitals in a specific geographic region.

An integrated delivery system (IDS) is a network of defined population and is willing to be held clinically and fiscally accountable for the clinical outcomes and health status of the population served. Services provided by an IDS can include a fully equipped community or tertiary hospital, home healthcare, and hospice services, primary and specialty outpatient care and surgery, social services, rehabilitation, preventive care, health education and financing, and community provider offices. An IDS can also be a training location for healthcare professionals, students, including physicians, nurses, and allied health professionals.

Accreditation and quality standards

Accreditation is considered the highest form of recognition for the quality of care a facility or organization provides.

It indicates to the public that the facility is concerned with providing high-quality care, and it also provides professional liability insurance benefits, and plays a role in regulatory agency licensure and certification efforts.

Hospitals and other healthcare facilities are accredited by the Joint Commission, an organization that promotes and evaluates the quality of care in healthcare facilities. Standards or indicators have been developed to help determine when patients are receiving high-quality care.

The term quality refers to much more than whether the patient liked the food served or had to wait to have a procedure or test performed.

Categories of compliance include the following:

  • Assessment and care of patients
  • Use of medication
  • Plant, technology, and safety management
  • Orientation, education, and training of staff
  • Medical staff qualifications
  • Patient’s rights

National Patient Safety Goals

Accreditation by the Joint Commission is required to obtain reimbursement from Medicare, managed care organizations, and insurance companies.

Besides accrediting healthcare facilities, the Joint Commission carefully evaluates patient safety. It has established the National Patient Safety Goals, which must be addressed by member facilities.

The 2021 safety goals for ambulatory organizations took effect January 1, 2021, and include the following:

  • Identifying patients correctly
  • Using medicines safely
  • Preventing infection
  • Prevent mistakes in surgery

Ambulatory care

Ambulatory care centers include a wide range of facilities that offer healthcare services to patients who seek outpatient health services. Physician’s offices, group practices, and multispecialty group practices are common types of ambulatory care facilities, and medical assistants can be employed in all of these practices.

Group practices may involve a single specialty, such as pediatrics or may be multispecialty. A multispecialty practice might consist of an internal medicine physician, an oncologist, a cardiologist, and an endocrinologist.

The providers of the practice refer patients to each other when indicated. This is therefore more convenient for the patients and tends to be more profitable for the members of the practice.

Sidenote
Important!

A patient seeing a provider for the first time is considered to be a New patient, whereas a patient who has seen the provider on previous occasions is known as an established patient.

Most providers charge new patients more than established patients due to the extent of the physical examination, the levels of decision-making, and the complexity of the medical history. New patient’s medical history may require more time.

Specialized ambulatory care facilities

Occupational health centers are committed to helping patients return to work and productive activity. Often, physical therapy is used in conjunction with rehabilitation services to assist the patient in regaining as much of his or her previous level of abilities.

Pain management centers can help patients deal with discomfort associated with their condition.

Sleep centers diagnose and treat patients with sleep conditions.

Urgent or emergency care centers provide patients with an alternative to hospital emergency departments (EDs) and are often open when traditional providers’ offices may be closed.

Ambulatory surgical centers

Surgery has become more convenient because of the number of ambulatory surgical centers that exist today. Many insurance companies now prefer day surgery because it is more cost-effective.

A wide variety of outpatient surgical facilities are available, offering procedures in ophthalmology, plastic surgery, and gastrointestinal concerns, including colonoscopies and endoscopies.

Additional ambulatory care facilities

Dialysis centers offer services to patients with severe kidney disorders, and many of the larger cities across the country have cancer centers for patients needing treatment by an oncologist.

Other types of ambulatory care facilities are centers that provide magnetic resonance imaging (MRI), student health clinics, dental clinics, community health centers, and women’s health centers.

Other healthcare facilities

Several other healthcare facilities deserve attention in the broad overview of a healthcare industry.

Laboratories

Laboratories offer testing services for patients referred by providers.

The enactment of CLIA in 1967 and its amendment in 1988 established that the only laboratory tests that can be performed in a physician’s office lab are those designated as CLIA (Clinical Laboratory Improvement Amendments) waived.

You will learn how to perform a variety of CLIA-waived tests in your medical assistant program.

Smaller or independent practices typically have to send non-CLIA-waived tests to an outside diagnostic facility.

Tests that can be performed in a physician’s office are known as point-of-care testing (POCT).

Home healthcare and hospice care

Home health agencies or hospital-affiliated home healthcare organizations provide crucial services to patients who may require medical follow-up but are not in a hospital setting.

Home healthcare includes therapy services, administration of and assistance with medications, wound care, and other services so that the patient may remain at home, yet still obtain consistent medical attention.

Hospice care is a type of home health service that provides medical care and support for patients facing end-of-life issues and their families.

The goal of hospice is to provide peace, comfort, and dignity while controlling pain and promoting the best possible quality of life for the patient.

Some communities have inpatient hospice services available either in a special unity in a hospital or in an independent hospice center.

Key points

The history of medical assisting

  • Originated from need for both administrative and clinical support in physician offices
  • Early medical assistants trained on the job; now formal education widely available
  • Medical assisting is a respected allied health profession

Allied health professionals

  • Work under authority of licensed medical practitioners
  • Include a broad range of roles beyond doctors and nurses

Who are allied health professionals?

  • Examples: respiratory therapists, technologists, dental hygienists, medical assistants, pharmacy technicians
  • Two main categories: technicians (assistants) and therapists
  • Therapists and nurses require state licensure and advanced degrees

Allied health professionals as part of the healthcare team

  • Make up about 60% of healthcare workforce in the U.S.
  • Over 5 million allied health professionals in 80+ professions
  • Provide diverse services in various healthcare settings

Types of healthcare facilities

  • Healthcare delivered in multiple settings, not just hospitals

Hospitals

  • Classified by care level: primary (community), secondary (specialty), tertiary (referral/complex cases)
  • Ownership types: private (for-profit), nonprofit (community-focused)
  • Hospital systems: groups of affiliated facilities; IDS (Integrated Delivery System) offers comprehensive care and training
  • Accreditation by Joint Commission required for reimbursement; focuses on quality and patient safety
    • Key compliance areas: patient care, medication use, safety, staff training, patient rights
    • National Patient Safety Goals: patient identification, safe medication use, infection prevention, surgical safety

Ambulatory Care

  • Outpatient services: physician offices, group/multispecialty practices, urgent care, ambulatory surgical centers
  • New vs. established patients: new patients require more extensive evaluation
  • Specialized centers: occupational health, pain management, sleep, dialysis, cancer, MRI, student health, dental, community health, women’s health
  • Ambulatory surgery preferred for cost-effectiveness

Other healthcare facilities

  • Laboratories: perform CLIA-waived and point-of-care tests; non-waived tests sent to external labs
  • Home health agencies: provide medical care at home, including therapy, medication, wound care
  • Hospice care: supports end-of-life patients and families, focusing on comfort and quality of life
    • Available as home service or in specialized inpatient units

More from Medical assistant

  • The professional medical assistant
  • Standards of care
  • Achieving a credential
  • Teamwork and the patient-centered medical home