Introduction

The purpose of a physical examination is to determine the patient’s overall state of well-being. All major organs and body systems are checked during a physical examination. As the entire body is examined, the provider interprets the findings. By the time the examination has been completed, the provider has formed an initial diagnosis of the patient’s condition. Laboratory and other diagnostic tests are often ordered to supplement the provider’s clinical diagnosis. The results of these tests are used to do the following:

• Refine the patient’s diagnosis
• Help the provider plan or revise treatment for the patient
• Evaluate and maintain current drug therapy
• Determine the patient’s progress

Before the examination, the medical assistant has the opportunity to make sure the patient feels comfortable during the examination process and that all the necessary medical information has been obtained. The medical assistant’s duties include preparing and maintaining the examination room and equipment, preparing the patient, and assisting the provider during the physical examination.

Preparing the examination room

The medical assistant is responsible for making sure the examination room is ready for any procedure that might be performed during the physical examination. The area should be as comfortable as possible for the patient and free of any potential dangers, such as contaminated equipment or unlocked drug cabinets. You should prepare the examination room as follows:

• Check the area at the beginning of each day and between patients to ensure it is completely stocked with equipment and supplies and that all equipment is functioning properly. You must understand how to take care of and operate all equipment and instruments, and you should refer to operation manuals supplied by manufacturers as needed.
• Regularly check expiration dates on all packages and supplies; discard expired materials.
• Make sure the room is private, well lit, and at a comfortable temperature for the patient during the physical examination.
• Clean and disinfect the area daily and between patients to prevent the spread of infection and to ensure patients’ comfort. When the patient leaves the room, discard the used exam table paper. Using disinfectant wipes, clean the table and any other potentially contaminated surface. When the table dries, replace the exam table paper.
• Arrange drapes, gowns, and all other patient supplies before the patient enters the room so that they are ready for use.
• To save time, prepare the instruments and equipment needed for the examination, arranging them for easy access before the provider enters the room.
• Make sure the examination room has all materials required for observing Standard Precautions, including gloves, a sink with soap, paper towels, biohazard waste containers, sharps containers, and impervious gowns and face guards. Sharps containers are replaced when they are two-thirds full, as indicated by Standard Precautions.

Assisting the patient

Getting the patient ready for the examination includes taking care of paperwork before the patient enters the examination room and performing related clinical skills:

• Make sure the health record is complete and that any needed consent forms have been signed; document current medications and allergies; identify any medications that need refills. Medical assistants are not responsible for obtaining informed consent, but they should review the paperwork to ensure that the provider has reviewed the informed consent forms and that the patient signed the forms.
• Introduce yourself, verify the patient’s identity, and use the patient’s preferred name, making sure to show respect at all times. Pay close attention to the nonverbal language cues to make sure the patient understands what to expect.
• Obtain specimens (e.g., urine, blood) if the provider has preordered them or if this practice is part of the office policy.
• Measure and record the patient’s height, weight, body mass index (BMI), and vital signs.
• Conduct the initial investigation into the reason for the visit and explain the examination procedure to the patient. Be prepared to answer the patient’s questions and ease any fears. If needed, refer the patient’s questions to the provider.
• Ask whether the patient needs to empty her or his bladder before the examination because a full bladder may interfere with the examination and can be uncomfortable for the patient.
• Help the patient physically prepare for the examination. Explain to the patient what clothing should be removed and what direction to put on the gown (open to the front or the back, depending on the type of examination); provide a drape to ensure the patient’s privacy and help as needed.
• Assist the patient in and out of various examination positions as needed.
• Throughout this sequence of events, explain what is happening and consistently maintain the patient’s privacy and confidentiality.
• Help the patient with dressing as needed after the examination.

Assisting the provider

The medical assistant should be prepared to help the provider complete the physical examination as comprehensively and efficiently as possible. During the examination, the provider may expect the medical assistant to do the following:

• Hand the provider instruments and equipment as requested and provide supplies as needed.
• Alter the position of the light source to better illuminate the area being examined and turn lights on and off during specific phases of the examination.
• Position and drape the patient during different phases of the examination.
• Assist in collecting and properly labeling specimens such as urine, Pap test specimens, and throat cultures.
• Conduct any diagnostic tests pre ordered by the provider, including hearing and vision screenings.
• Conduct follow-up diagnostic procedures as ordered, including an electrocardiogram (ECG, EKG), urinalysis, and phlebotomy.
• Document patient data in the health record, completing all forms required.
• Schedule post-examination diagnostic procedures, such as mammography, x-ray examination, or colonoscopy.