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A discharge summary report may include all of these details, but it is essential that it include details of the patient's final condition. If this is not provided, ensure you obtain it from the patient's physician. When this is not properly recorded it could open the way to legal action should the patient develop later complications.
However good an office's systems may be, it is good practice to check appointments with each team member every day. This ensures that all staff are well prepared and should eliminate double bookings, cancelled appointments etc.
Always make sure that only you or authorized colleagues can see the screen you're working on. This will minimize the chances of confidential data being accidentally displayed to unauthorized personnel.
Every year some institutions will be caught disposing of contaminated sharps in ordinary trash or non-approved containers. This increases the risk of infection for garbage collectors and the general public; never cut corners if it's your responsibility to dispose of sharps, always insist on an FDA approved container.
Taking a patient's pulse is not simply a matter of counting the beats per minute. You should be able to distinguish between a strong and a weak pulse and to identify any irregularity in the pulse rate (missing beats, sudden acceleration/deceleration etc.).
There are often medical circumstances – for example emergency resuscitation – where a patient’s consent cannot be obtained. However, even if a patient is unable to give or withhold consent (e.g. if unconscious) private information must not be divulged to third parties. (There are certain very specialized circumstances, e.g. gunshot wounds, where information may be divulged to very specific third party agencies, e.g. law enforcement)
The recommended longest lancet for taking a blood sample from the heel of a newborn baby is 2.4 mm. Care should be taken not to take the sample from the back of the heel where the distance from the skin surface to the bone can be as little as 2.33 mm. If in doubt, or if the child is premature or underweight, use a smaller lancet.
It is vital that all medical personnel are up-to-date with all applicable licenses, certificates etc. A medical office should keep a thorough record of these matters and issue reminders to staff when updates are required; the office itself can be held responsible if it is employing staff whose licenses etc. have lapsed.
The monitoring of vital signs comprises monitoring temperature, respiration and pulse. However, at the same time as monitoring the vital signs any other abnormal signs should be noted, for example excessive sweating, trembling or incoherence, and reported if necessary.
An ECG test requires a clear flow between electrodes: any thickening of the skin or metal objects may impede this. Do not place electrodes over piercings, scars or stents or in such a way that these elements may interfere with results.
Drugs that cause vomiting are called emetics. They are often used for patients who have deliberately or accidentally consumed harmful substances, or substances in harmful doses, e.g. alcohol, painkillers. When administering an emetic remember the process of vomiting may leave the patient dehydrated and take steps to prevent this.
Some drugs can be administered transdermally via a patch on the skin. This can be a good option for patients who are frightened of needles and for those requiring a steady release of a drug over time.
Although every precaution should be taken to avoid needlestick injury, and treatment should be sought immediately should one occur, the risk of contracting HIV from a needlestick injury is extremely low. The Department of Health calculate the risk, when a medical worker has been stuck with a needle contaminated with HIV+ blood, of contraction as being 0.3%, i.e. it will happen three times in every 1000 incidents.
Medical transcription is often part of a medical assistant's duties. Special care should be taken with accuracy when undertaking transcription and you should seek the physician's guidance on any matters that are unclear or terms that you do not understand.
Chain of custody procedures must be followed for legally sensitive tests. If you're involved in such tests make sure that all paperwork is correctly filled and that you have correctly signed off your part of the testing to the next person in the chain.
As the gauge number increases so the bore of the needle becomes smaller. Always take special care to select the appropriate needle, or you may cause excessive post-draw bleeding or have to make multiple attempts, both of which will cause distress for your patient.
All abnormalities in vital signs could be crucial indicators that a patient needs immediate treatment. Any abnormalities must be reported to a physician immediately.
In addressing someone whose name you don’t know, you should always use “Yours sincerely.” “Yours faithfully” should only be used if a letter is addressed to a specific person, and “Kind regards” only for a person you know and have had some positive interaction with previously.
Petty cash is the sum of money held in the office to meet immediate office running needs. It should not be used for staff loans or advances on salary; borrowing from petty cash without authorization, even if there is a genuine intention to return the borrowed sum, could be classified as theft.
People may often have reasons to avoid appearing in court cases. This is why courts have the power to issue a subpoena that compels a person or organization to appear and give evidence. Subpoena means, in Latin, “under threat of punishment”, and failure to obey such an order may incur legal penalties.
