Delmar Learning’s Clinical Handbook for the Medical Office

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ISBN: 9781401832858 | 1401832857
Cover: Spiral Bound
Copyright: 9/18/2003

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This handbook for medical assistants and physician office personnel provides numerous charts for quick referencing. Organized in an easy-to-read chart format, main topic areas include documentation, in-office and telephone assessment, normal lab values, commonly prescribed drugs, and clinical procedures. OB-Gyn and pediatric specialty sections are also included.

Preface	p. xi
Acknowledgments	p. xv
Common Medical Abbreviations
General Abbreviations	p. 2
Measurement Abbreviations	p. 14
Pharmacology Abbreviations	p. 15
Symbols	p. 17
Documentation Basics and Conducting In-office Screenings
Introduction	p. 20
Documentation Basics	p. 21
Documentation Don'ts	p. 22
Simplified Chief Complaint	p. 23
Comprehensive Chief Complaint	p. 25
Gathering Questions for the History of the Present Illness	p. 28
How to Use the Chart	p. 28
Quick Glance History of the Present Illness (HPI) and Anticipation Chart	p. 29
Follow-Up Appointments/Progress Notes	p. 41
Documenting Medications	p. 43
Documenting Prescriptions	p. 46
Charting In-House Procedures	p. 48
Completing and Documenting Referrals	p. 50
Pre-certification/Documenting Outside Procedures	p. 53
Telephone Screening	p. 56
Documenting Patient Education Sessions	p. 59
Telephone Screenings
Introduction	p. 64
How to Use the Charts	p. 65
Action Abbreviation and Code Key	p. 67
Abdominal Pain/Stomach Pain	p. 69
Allergic Reaction/Anaphylaxis	p. 73
Anxiety and Stress	p. 75
Back Pain	p. 77
Burns	p. 79
Chest Pain	p. 84
Colds, Cough, and Flu	p. 87
Constipation	p. 89
Depression	p. 91
Diarrhea	p. 94
Ear Pain	p. 97
Eye Disorders	p. 100
Fainting	p. 103
Fever	p. 106
Headaches and Head Trauma	p. 109
Insect Bites or Stings	p. 113
Nosebleeds	p. 116
Rashes and Skin Disorders	p. 118
Strains, Sprains, and Fractures	p. 124
Urinary Tract Symptoms	p. 128
Vaginal Symptoms	p. 131
Wounds, Abrasions, Bruises, Lacerations, and Punctures	p. 134
Assisting in an OB-Gyn Practice
Introduction	p. 138
Annual Pap and Pelvic Procedures	p. 139
Pap Tray	p. 140
Pelvic Exam	p. 141
Pelvic Tray	p. 142
Assisting with a Colposcopy and a Biopsy Punch	p. 143
Assisting with Cryosurgery or Cryotherapy	p. 145
Diseases That Can Be Spread through Sexual Contact	p. 146
Sexually Transmitted Diseases	p. 147
Gynecological Diagnostic Tests and Procedures	p. 149
Assisting with Obstetrical Exams	p. 149
Assisting with the Prenatal Exam	p. 151
Diagnostic Tests and Procedures Routinely Performed During Pregnancy	p. 153
Assisting in a Pediatric Office
Introduction	p. 158
Assisting with Routine Pediatric Exams	p. 159
Recommended Childhood and Adolescent Immunization Schedule	p. 161
Telephone Screening for the Pediatric Patient	p. 161
Common Pediatric Diseases and Disorders	p. 164
Pharmacology
Introduction	p. 170
Drug Classifications	p. 171
Most Commonly Prescribed Medications	p. 176
Over-the-Counter Medications	p. 187
Most Common OTC Medications	p. 188
Common Childhood Immunizations	p. 190
Common Adult Immunizations	p. 194
Common Injectables	p. 197
Prescription Writing	p. 199
Laboratory Regulations and Laboratory Normal Values
Introduction	p. 202
Clinical Laboratory Improvement Act (CLIA)	p. 203
Process for Obtaining a Certificate of Waiver	p. 204
Process for Obtaining a Certificate for Moderately Complex or Highly Complex Labs	p. 204
Agencies Approved to Perform CLIA Inspections	p. 204
Provider-Performed Microscopy (PPM)	p. 205
Occupational Safety and Health Administration (OSHA)	p. 206
Exposure Control Plan	p. 206
Communication of Hazards to Employees	p. 206
Post-Exposure Evaluation and Follow-Up Procedures	p. 207
Record Keeping	p. 207
Other Terms	p. 208
Common Chemistry Tests	p. 209
Common Hematology Tests	p. 212
Critical Lab Values	p. 215
Organizational Tips	p. 215
Staff Responsibilities for Handling Critical Labs	p. 215
Radiographic Procedures
Introduction	p. 220
Information Needed When Ordering X Rays	p. 221
Routine Flat Films	p. 222
Ultrasound	p. 224
Computerized Tomography (CT Scan)	p. 225
Magnetic Resonance Imaging (MRI)	p. 226
Routine Procedures Performed in the Medical Office
Introduction	p. 228
Bandaging	p. 229
Assisting with Cardiac Procedures	p. 231
Electrocardiograms (3-Channel Version)	p. 232
Holter Monitor Application	p. 236
Ear and Eye Procedures	p. 239
Ear Instillation	p. 239
Ear Irrigation	p. 241
Eye Instillation	p. 243
Eye Irrigation	p. 246
Visual Acuity Testing	p. 248
Color Vision by Ishihara Method	p. 250
Measuring Near Vision (Jaegar Procedure)	p. 251
Emergency Procedures	p. 253
Foreign Body Airway Management for the Conscious Patient	p. 253
Cardiopulmonary Resuscitation for the Health Care Provider	p. 255
Crash Cart Equipment	p. 257
Laboratory Procedures	p. 258
Capillary Puncture Procedure	p. 258
Hematocrit/Finger Puncture Method	p. 261
Hemoglobin (Hemoglobinometer Method)	p. 263
Blood Glucose (Glucose Meter Method)	p. 265
Glucose Tolerance Test (GTT)	p. 266
Venipuncture	p. 269
Venipuncture (Evacuated Tube Method)	p. 269
Venipuncture (Syringe Method)	p. 272
Venipuncture (Butterfly Method)	p. 274
Vacuum Tube Stopper Color Chart	p. 276
Tube Order for Vacuum Method	p. 278
Hematoma Prevention Tips	p. 278
Rapid Test Kits	p. 279
Performing an HCG Urine Pregnancy Test	p. 279
Obtaining a Throat Swab and Performing a Rapid Strep Test	p. 280
Urinary Procedures	p. 282
Collecting a Clean Catch Urine Sample	p. 282
Collecting a 24-Hour Urine Specimen	p. 284
Physical Urinalysis	p. 286
Measuring Specific Gravity	p. 289
Performing a Chemical Urinalysis	p. 291
Microscopic Analysis of Urine	p. 295
Medication Administration	p. 298
Adult Dosage Calculations	p. 298
General Guidelines for Administering Medications	p. 303
Administering Oral Medications	p. 305
Withdrawing Medication from a Vial	p. 307
Combining Two Drugs into One Syringe	p. 308
Withdrawing Medication from an Ampule	p. 310
Administering an Intradermal Injection	p. 311
Administering a Subcutaneous Injection	p. 313
Administering an Adult Intramuscular Injection	p. 317
Administering a Z-Track Injection	p. 322
Minor Surgical Procedures	p. 323
Aseptic Procedures	p. 323
Medical Aseptic Handwashing	p. 326
Surgical Gloving	p. 327
Application of Sterile Adhesive Skin Closures	p. 329
Removal of Sutures	p. 331
Tray Setups	p. 334
Complete Physical Exam	p. 334
Cyst Removal	p. 335
Eye, Ear, Nose, and Throat Tray	p. 336
Electrosurgical Tray	p. 337
Excision Trays (Mole, Skin Tags, and Wart Removal)	p. 337
Incision and Drainage or ID Tray	p. 338
Joint Injection	p. 339
Laceration/Suture Tray	p. 340
Lumbar Puncture Tray	p. 341
Rectal Exam	p. 341
Sigmoidoscopy	p. 342
Positioning	p. 343
Vital Signs	p. 346
Blood Pressure (Palpatory Method)	p. 346
Measuring a Radial Pulse	p. 349
Measuring an Apical Pulse	p. 351
Measuring Respiration	p. 353
Measuring Temperature	p. 355
Instrument Identification
Introduction	p. 360
Illustrations of Instruments	p. 362
Hugs in the Hallway
Introduction	p. 372
Setting the Scene for Hugs in the Hallway	p. 373
She Couldn't Come to Their World, So They Went to Her World	p. 373
"You Want My Picture?"	p. 375
Fond Memories	p. 378
Fond Memories Continued	p. 379
"I Can't Find the Pound Key"	p. 379
Bibliography	p. 381
Index	p. 383
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Delmar Learning’s Clinical Handbook for the Medical Office

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