Uses Of Computer For Medical Assistants

When computerizing a medical office, it is important to know what to expect, to understand the uses and limits of computers, and to organize the transition thoroughly, with proper attention to these details:    
1. Know what the office needs in a computer system. To be useful, a computer system must serve the needs of the facility. Make a list of why you want the computer: it might include word processing, insurance claim filing, and managing a database. You also might want on-line and E-mail capabilities.    
2. Network by talking to other people in the medical industry. It is advisable to ask questions of other ambulatory care centers that have been through the manual-to-computerization process. Ask them what computer hardware they prefer, what software applications they advise for different functions, and what problems they encountered during their transition.    
3. Work with a trusted, knowledgeable vendor. It is important to establish a relationship with a computer vendor who understands not only computers but the needs of a medical office. Reliable vendors should be able to advise you of the best system and software and help you anticipate and allow for future needs as the medical practice grows.    
4. Involve all staff members. If staff members are not familiar with the use of computers, they may feel threatened and, initially, think that using a computer is more time-consuming than doing a task manually. The transition takes time and training. Organize staff training sessions, either on- or offsite, so that all employees are familiar with the basics of computer operation.    
5. Install the operation during a down period. The installation of a computer network can be very disruptive to patients and the office environment. If possible, schedule the installation during a down period, such as over a long holiday when the office is closed, or at least after office hours.    
6. Allow adequate time for start-up. Initially, much data from existing records will have to be entered. This is an onerous and time-consuming task, but one that must be done with great accuracy. Do not expect the computer system to be 100 percent operational immediately. Allow time for medical records and other data to be entered and for staff to build confidence in their computer skills.

Office Design And Environment For Medical Assistant

Office Design and Environment:
Even when the office or clinic is housed in an older building not originally constructed as a medical facility, there is much that can be done to create an environment that enhances patient comfort. Remember to see things from the patient's point of view. If the facility is a labyrinth of corridors where patients can easily get turned around, make certain that directions are clear. Be sure that examination rooms are not made more frightening by an assortment of exposed medical equipment and strange-looking dials, hoses, and nozzles. Be alert to odors that are often distasteful to patients even if the odors are from necessary antiseptics.

A reception window or desk should not make the patient feel closed off from the receptionist; it should provide privacy for the receptionist while allowing a full view of the reception area. A poorly illuminated room may suggest that the physician is trying to hide somethingpoor housekeeping, dust-encrusted baseboards, soiled carpets, or faded draperies. Lighting can be soft and inviting while providing proper illumination.
Some rooms in the facility, by their very nature, cause patients to feel intimidated. Consider the patient who is naked on an examination table except for a paper or cloth gown interacting with the physician who is fully clothed and wearing a white lab coat and comfortably seated at a counter desk. Consider also the patient who is about to have a sigmoidoscopy and must be placed on a special examination table tilted into the knee-chest position. Both these situations place the patient at an unequal level with the physician for discussion and negotiation. The goal in medical care should be to empower the patient with as much control as possible.

Privacy is always important to patients. Provide space for them to hang their clothes and undergarments out of view. A mirror is especially helpful when dressing. Always ask if a patient needs help in disrobing, and always knock before entering a room. Remember, too, that privacy implies that the patient's conversation cannot be overheard in any other part of the facility. Color can do much to establish an inviting environment. Greens and blues are good in areas that require quiet and extended concentration. Cool colors cause individuals to underestimate time and make heavier items seem lighter, objects smaller, and rooms larger. Warm colors with high illumination cause increased alertness and an outward orientation.

The aged will have difficulty distinguishing pastels because of failing eyesight. Strongly contrasting patterns and extremely bright colors can be overwhelming, and even intimidating or threatening in their effect. Accessories and artwork can easily add a special touch to a facility. While fresh flowers might be a nice touch, fresh flowers harbor microorganisms, and some patients may be allergic to them. There is the tendency to use living plants in the medical facility, but some silk plants and flowers look realistic. It would be worth the investment to have a professional designer look through the facility to make suggestions regarding color, artwork, and the general environment of the office.    

Facility Environment And Reception Area

The environment of the medical office or clinic contributes almost as much to a patient's well-being as does the medical attention given by the physician and medical assistants. The physical environment can foster a feeling that embraces and welcomes patients or causes them to feel alienated and intimidated. Interior designers and experts in space planning are advising all individuals involved in designing clinics, medical offices, and hospitals that patient comfort must be considered as important as the facility's functional utility and ease of maintenance. The Americans with Disabilities Act (ADA) also must be taken into account when creating any medical office environment, and provisions must be made to accommodate patients who are physically challenged. The creation of a health care facility involves many variables. Some are concrete elements, such as lighting, color choice, and furniture arrangement. Yet others are intangible and are expressed in a receptionist's greeting and attitude toward patients. Together, these elements make an ambulatory setting the kind of environment where patients will feel comfortable and secure.

The Reception Area:
A reception area is just thata place of reception; it should never be thought of as the waiting room. This is the area that can make the patient feel welcome, secure, and comfortable. Adequate and comfortable seating affords patients room to have their own space. Proper seating placement also respects cultural biases. For example, some Americans do not like to be touched by strangers. Middle Eastern and Latin cultures, by contrast, encourage closeness and touching, and individuals from these cultures may cluster themselves close together in the reception area. Current magazines that are appropriate to the clinic clientele, plants, and other features such as a professionally maintained built-in aquarium will help set a welcoming tone. The fabric and texture of draperies, upholstery, and carpet should be pleasing, comfortable, and easy to maintain. It is helpful if there is a place for patients to hang heavy coats or wet umbrellas. Many physicians provide educational materials for patients in the reception area. For example, new parents always appreciate pamphlets related to raising children. It is also appropriate to have available in the reception area a patient information brochure that describes the services of the office, the function of medical staff members, measures to take in case of an emergency, and other issues that patients may need to consider.

Computer Use in the Ambulatory Care Setting

In a little more than a decade, computers have revolutionized the world of health care. They have assisted in performing sensitive surgeries, diagnosing illnesses, and developing patient treatment strategies. In addition to these dramatic clinical applications, computers have changed the nature of the ambulatory care setting from an administrative point of view, streamlining critical tasks such as patient data collection, correspondence, reports, and insurance claim filing. Yet, by itself, the computer cannot make a medical practice function more smoothly. Talented medical assistants, who understand the uses and potential of the personal computer, are the key behind an effective computerized office.
Inner City Health Care, an urgent care center in a large urban area, recently made the transition from a manual to a computerized system. It was a change long overdue, and it required a great deal of fact-finding and research before office manager Walter Seals could convince the center's physicians to purchase a network of computers for the five-physician center. Once he persuaded his employers of the computer's potential value to the center, Walter, an administrative medical assistant, proceeded very carefully. He spoke with other ambulatory care settings that were already computerized, in order to establish benchmarks, or comparisons. He selected a computer vendor who was familiar with the software needs of a medical office. He made sure all staff would receive training in the use of the computer. Finally, he selected a two-week period when the office was routinely closed for summer vacation to have the computer system installed and operational. Most ambulatory care centers either are or soon will be operating under a computerized system. The medical assistant who is familiar with the many applications of the computer and comfortable in its use is a great asset to any ambulatory care setting.

Americans with Disabilities Act And The Receptionist's Role

Accessibility, or making facilities and equipment available to all users, is a major consideration when creating the health care environment. The Americans with Disabilities Act (ADA) was passed by the United States Congress in 1990. The purpose of this act is to provide a clear and comprehensive national mandate to end discrimination against individuals with disabilities and to bring them into the economic and social mainstream of life. In addition to accessibility regulations, this act also provides employment protection for persons with disabilities. ADA applies to businesses with fifteen or more employees; however, some states may have stricter legislation. Even before ADA became legislation, most health care facilities attempted to make their premises barrier-free and accessible to patients with special needs. While many ambulatory care settings will have less than fifteen employees, accessibility for all patients in all settings is very important.

A professional designer can provide advice on how the facility must be accessible to persons who are physically challenged. For example, all doors and hallways must accommodate a wheelchair. There must be a bathroom facility available for handicapped individuals. Signage in Braille accommodates patients with visual disabilities. Elevators must be provided if the facility is on more than one level. Be alert also, to patients whose impairment is not obviousindividuals with impaired hearing or vision and individuals whose infirmity (temporary or permanent) may prevent them from doing certain physical activities.

The receptionist is the person on the health care team who must always keep a positive ''We can help you" attitude, have a smile for each patient, and a genuine "I care about you" personality. This individual, who often is a medical assistant with other duties as well, must be able to perform telephone triage, retrieve records, greet patients, present a bill, make appointments, and log data into the computer all the while remembering that the patient's comfort is of primary concern. The receptionist must genuinely like people and not be upset when they are grumpy, irritable, or depressed and worried about an illness.

The receptionist is the person who sets the social climate for the interchange between the patient and the physician and the rest of the staff. Patients who are very ill should not have to wait in the reception area, but should be shown to an examination room away from other patients. The receptionist or medical assistant may also have to entertain children who may be intent on disrupting patients. This is especially necessary if the parent seems unconcerned about keeping youngsters under control. If there are unexpected delays in the physician's schedule, be certain to notify patients of the delay tactfully and graciously and offer them the alternative of making other arrangements. Keep in mind that the patient's time is as valuable as the physician's.   

Opening and closing the Facility

When the facility is opened in the morning, everything should be in readiness. The receptionist or administrative medical assistant, who arrives at least twenty minutes before the first patient, will make a visual check of each room to be certain it is prepared and ready for the day. Rooms should be of a comfortable temperature, well-organized, pleasantly illuminated, and spotless. All necessary supplies and equipment should be checked for readiness. At all times, patient comfort and safety should be paramount. Patient charts for the day should be retrieved if not done so the prior evening. The receptionist will also check the answering service or machine for any telephone messages. An effective way to check a room's readiness is to place yourself in the room as a patient. Ask yourself how you feel about being there, what mood the surroundings create for you, and whether you would feel welcome and comfortable as a patient. At the close of the day, each room should be checked to make certain all equipment is shut down and doors and windows are secured. Be sure that all materials of a sensitive nature are under lock and key (this is not easily accomplished in facilities that use open-shelf filing, however). Any drugs identified in the Controlled Substances Act list of narcotics and non-narcotics must be in a locked and secure cabinet and should also be checked when leaving the office. Any petty cash kept on the premises must be locked in a safe container. It is best, also, to put each room and area in readiness for the next day. Local law enforcement officers can advise you on appropriate indoor and outdoor lighting as well as any other security measures to make both during and after office hours. Always contact the answering service to notify them that the office is closed and where and how the medical staff can be reached in an emergency. Keep in mind that the environment in which patient care is given must promote health rather than aggravate illness and feed anxiety. The environment must be clean, fresh, cheerful, and nonthreatening with contemporary furnishings, appropriate colors, proper lighting, and soothing textures. Even if patients are not consciously aware of the message they are getting from the office design and environment, they are subconsciously receiving it. The office environment reveals things that might subconsciously undermine a patient's confidence in the physician and the health care team.    

Subpoenas Confidentiality & Statute of Limitations

1) Subpoenas
The medical records may be subpoenaed and/or the physician and health care provider (subpoena ducestecum) may be subpoenaed to testify in court. The subpoena is a court order naming a specific date, time, and reason to appear. The staff in the ambulatory care setting usually will have ample time to make certain the record is current and complete prior to its inclusion in court. Out of courtesy, the physician will notify patients whose records have been subpoenaed. If, for any reason, the patient does not want the record released, the physician must call for legal advice on how to respond to the subpoena.
Certain records, because of their sensitive nature, may require more than a subpoena to be released. These include records related to sexually transmitted diseases, including AIDS and HIV testing, mental health records, substance abuse records, and sexual assault records. For the courts to have access to these records, a court order is required in some states.    

2) Confidentiality    
The care taken with subpoenas and court orders for certain information is to assure patients of confidentiality. The information in the medical record, including the information a patient shared with the physician and medical assistant, is private.    

No patient information can be given to another (another physician, patient's attorney, insurance company, federal or state agency) without the expressed written consent of the patient. Care must be exercised at all times to ensure that the patient's right to confidentiality is not breached. For example, information given to unauthorized personnel associated with the physician's or clinic's practice in regard to the patient's condition or financial status regarding payment of bills violates the patient's right to confidentiality. Likewise, when discussing issues over the telephone that can be overheardsuch as the patient's account being turned over to a collection agencythe patient's right to confidentiality has been violated. There are certain disclosures of information about a patient's conditions and suspected illnesses that are required by law. Legally required disclosures are necessary when the public needs to know certain information for its safety and welfare. The disclosures supersede the patient's right to privacy and confidentiality. See ''Public Duties" in this chapter.

3) Statute of Limitations
No discussion of medical records is complete without a brief statement regarding the statute of limitations which will, in part, determine how long medical records are kept. Generally speaking, all records should be retained until after the statute has run, usually three to six years. Statutes of limitations most commonly begin at the time a negligent act was committed, when the act was discovered, or when the care of the patient and the patient-physician relationship ended. It is easy to understand why many physicians choose to keep their records indefinitely.

State and federal statutes set maximum time periods during which certain actions can be brought or rights enforced; there is a time limit for individuals to initiate legal action. The statute of limitations varies from one jurisdiction to another and a lawsuit may not be brought after the statute of limitations has run. For example, in the Commonwealth of Massachusetts, the statute of limitations for an act of medical malpractice committed on an adult is three years. If harm to a patient resulted from a medical assistant administering the wrong dose of medication to a patient in Massachusetts, a lawsuit must be brought within three years from the time the medication error was made, with the three years commencing at the time the negligent act was committed.

Standard of Care and the points of Negligence

Physicians, medical assistants, and all health care providers have the responsibility and duty to perform within their scope of training and to always do what any reasonable and prudent health care professional in the same specialty or general field of practice would do. That is what is expected of every physician when a contact is made by a patient. Failure to do what any reasonable and prudent health care professional would do in the same set of circumstances can be seen as a breach of the standard of care. Negligence is defined as the failure to exercise the standard of care that a reasonable person would exercise in similar circumstances. The negligence occurs when someone suffers injury because of another's failure to live up to a required duty of care and is a primary cause of malpractice suits. Malpractice is professional negligence. The four elements of negligence, sometimes called the 4 Ds, are:    

a) Duty: duty of care    
b) Derelict: breach of the duty of care    
c) Direct cause: a legally recognizable injury occurs as a result of the breach of duty of care    
d) Damage: wrongful activity must have caused the injury or harm that occurred    

If an individual has knowledge, skill, or intelligence superior to that of a layperson, that individual's conduct must be consistent with that status. Medical assistants are held to a high standard of care by virtue of their skills, knowledge, and intelligence. As professionals, medical assistants are required to have a standard minimum level of special knowledge and ability. This is what is known as duty of care.    

Physicians and members of their staff may be called to testify in court to the standard of care. In such a case, they are usually considered expert witnesses. An expert witness is one who has knowledge and experience enough in a field to be able to testify to what is the reasonable and expected standard of care. Expert witnesses are expected to tell what they know to be fact and are best counseled to use lay terms rather than complicated medical language. The goal is for jurors and judges to understand the nature of any medical information shared. Visual aids, charts, and computer simulations are often used to illustrate or clarify testimony given by expert witnesses.

Risk management Torts And Medical Assistant

Some common areas of negligence may result in torts when the standard of care is not adhered to; practicing good risk management makes the medical assistant and the physician-employer less vulnerable to litigation.    

1) Protect patients from falling from an examination table, wheelchair, or stretcher.

2) Check for faulty electrocautery. Have repair done by qualified technicians.

3) Check patient identification by correctly identifying patient before performing a procedure or administering a medication.

4) Never leave a patient unattended. If you must leave, pass the responsibility for the patient's care on to another individual.

5) Be particularly watchful with patients who have special needs such as the elderly, pediatric patients, and those with physical and emotional disabilities.

6) Properly label and identify all specimens. Handle specimens properly.

7) Make certain the patient has signed a consent for surgery and other care.

8) Follow all policies and procedures established by your employer.

9) Do not misrepresent your qualifications.

10) Document fully only facts and do not alter medical records.

11) Admit any error that may have occurred.

Range of Psychological Suffering In AIDS

Health care professionals will always be called upon to care for patients who have infectious diseases, diseases not known to the medical community, or new diseases that are rare but that may become more common in the future. New diseases are likely to be seen when genetic change in causative organisms or changing modes of agriculture put human populations into contact with new pathogens. This is especially true in developing countries where populations are high, and people live in crowded conditions without proper sanitation. Even though health care professionals are prepared to respond to the medical, surgical, and psychological needs of patients, they face additional challenges when helping people with the acquired immunodeficiency syndrome AIDS, a deadly infectious disease.

One of the most important skills for medical assistants is the ability to respond to patients with special needs in an empathic way. Medical assistants will respond to the needs of patients with AIDS and individuals who test positive for the virus in an ambulatory care setting rather than a hospital or surgical center. In some measure, the ambulatory care setting removes the medical assistant from the demanding daily physical care of these individuals who can be so devastated by the ravages of AIDS. The psychological and emotional demands of the medical assistant, however, are as great, if not greater, than those placed upon health care professionals in a hospital or surgical center.

Infection with HIV causes extreme distress. The onset of symptoms is typically accompanied by the fear of developing AIDS. Distress is evident in the preoccupation with illness and patients' fears of getting cancer and other life-threatening diseases. Anxiety and depression are common. At the time of diagnosis, patients' responses may include denial, numbness, and inability to face the facts. Patients are angry at the disease, at the discrimination that often accompanies it, at the prospect of a lonely, painful death, at the lack of effective treatment, at medical staff, and at themselves. In many cases, guilt develops about past behavior and lifestyles, or about the possibility of having transmitted the disease to others. When the disease has been contracted through contaminated blood or blood products or by individuals who felt they were protected or safe from the disease, the anger may turn into rage. Sadness, hopelessness, helplessness, denial, and withdrawal are often exhibited. Some patients contemplate suicide. Because social and physical assistance are needed, a strong network of friends and family is particularly important. In the case of homosexuals and persons addicted to intravenous drugs, however, there are a large number who are estranged from their family's support system. Persons with AIDS may feel added strain if this is the first knowledge their families have of any high-risk behaviors associated with the transmission of disease. The psychological suffering leads to physical symptoms such as tension, tachycardia, agitation, insomnia, anorexia, and panic attacks. Persons who test positive for HIV often express an exaggerated sensitivity to disease and see any new symptom as bringing them closer to death.

As a medical assistant, you face the challenge of caring for persons with a life-threatening disease; you must comfort persons who face great suffering and death. You will become a source of information for patients with AIDS and their support members. You must be particularly sensitive and respectful toward individuals who are viewed as social pariahs. You will have to examine your own beliefs and lifestyle. You must be comfortable with your own sexuality and the sexuality of others whose lifestyle may differ from yours. You must replace any fear you have regarding the disease with knowledge based on medical fact, and always practice standard universal precautions As well as assisting your physician or employer in providing the best possible medical care, many nonmedical forms of assistance may be required by persons infected with HIV or AIDS. You may need to make referrals to community-based AIDS service groups, health departments, and to social workers for planning physical and financial assistance. Trained hospice volunteers or AIDS volunteers also are helpful to families and significant others, as well as to patients with AIDS.

There may be the need for patients with AIDS to obtain legal assistance and to identify their wishes and directions for care during the terminal stages of their illness. A living will or physician's directive might be encouraged. Refer to Chapter 10 for more information on physician directives. Patients who are losing mental acuity should be encouraged to appoint a legal guardian or durable power of attorney. As much as possible, be responsive to the family members or the significant others related to patients with AIDS. Answer any questions they may have regarding their fear of contracting the disease. It may be helpful to remind them that AIDS is difficult to contract, even among people at high risk for the disease. The risk of transmitting AIDS from daily contact at work, school, or at home is low. In virtually all cases, direct sexual contact or sharing of IV drug needles is the leading cause of transmission.

Maintaining Medical Records And Consent

A major responsibility of the physician and the medical assistant is to maintain an accurate and up-to-date record of the patient's care. Whatever style of record is used, the credibility of the medical record will be a key factor in any litigation. All matters related to a patient's care must be charted, and these charts must be an accurate reflection of actual care rendered and charges made. An act not recorded is generally considered an act not done. Charts that are incomplete or illegible are not easily defensible. Necessary corrections should be made by drawing one line through the error and placing the correction above it with the person's initials and date. All entries should be properly signed and dated, also. Consistency in the medical records becomes a powerful defense for the physician.

1) Informed Consent:
Documentation of informed consent becomes an important part of the medical records. Every patient has a right to know and understand any procedure to be performed. The patient is to be told in language easily understood:    
a. the nature of any procedure and how it is to be performed
b. any possible risks involved as well as expected outcomes of the procedure    
c. any other methods of treatment and those risks
d. risks if no treatment is given    

It is the responsibility of the health care provider to make certain the patient understands. If an interpreter is necessary, the physician must procure one.    
Often, consent forms will be signed if there is to be a surgical or invasive procedure performed (Figure 9-5). The medical assistant may be asked to witness the patient's signature and may be expected to follow through on any of the physician's instructions or explanations but is not expected to explain the procedure to the patient. The signed consent form is kept in the medical chart and a copy is also given to the patient.    

2) Implied Consent
Two circumstances related to consent are worth mentioning at this point. Implied consent occurs when there is a life-threatening emergency or the patient is unconscious or unable to respond. The physician, by law, is allowed to give treatment without a signed consent. Implied consent occurs in more subtle ways, also. The patient who rolls up a shirt sleeve for the medical assistant to take a blood pressure reading is implying consent to the procedure by the action taken.    

3) Consent and Legal Incompetence  
Consent for treatment is not valid if the patient is legally incompetent to give consent. Legal incompetence means that a patient either is found by a court to be insane, inadequate, or to not be an adult. In such instances, consent must be obtained from a parent, a legal guardian, or the court on behalf of the patient. Consent for treatment may be given only by the natural parent or legal guardian as determined by the court for a minor child, typically defined as one under eighteen years of age or the age of majority. An emancipated minor is one considered by the courts to be an adult. Emancipated minors may be defined as persons living on their own, who are self-supporting, who may be married, or who are in the military. They can legally give consent for treatment. Consent problems may arise when providing care to minors. Consent for medical care such as treatment of sexually transmitted diseases, pregnancy, alcohol or drug abuse, abortion, or birth control pose special problems. Some states allow minors to give their consent in these special situations.

Legal Public Duties And Drug Screening

Legal Public duties:

Physicians have a duty to the public to report diseases and injuries that jeopardize public health and welfare. Transmittable or contagious diseases and injuries resulting from knife or gunshot are examples and these must be reported to the appropriate authorities. This is done without the patient's consent because it is required by law. When reporting, it is important to do so properly and according to the laws in the state in which one is employed. Knowledge of which illnesses, injuries, and conditions to report, to whom to report, and the appropriate forms to submit is essential. Copies of all information must be kept for the office or clinic. Some states have laws specific to the release of information relative to mental or psychological treatment, human immunodeficiency virus testing, acquired immunodeficiency syndrome diagnosis and treatment, sexually transmitted diseases, and chemical substance abuse. Local or state health departments can provide lists of diseases and injuries to report and will also provide the appropriate forms.

Drug Screening:

States vary in the laws they have regarding the abuse of alcohol and other drugs. In general, employers are allowed to screen an employee for chemical substances if they believe the employee's work performance is being affected by the abuse. Great controversy surrounds pre-employment and random screening for drugs in the workplace. Some states allow widespread random testing of employees.
It is important that the worker's right to privacy not be violated. A tort of defamation of character could be claimed against an employer if the results of the testing become known to others. Get the patient's written consent when asked to collect a specimen for drug screening. Be certain the laboratory that performs the screening is qualified to perform the test. The possibility of liability is great if the ambulatory care setting does not have specific policies and procedures to employ in regard to specimen collection and testing. It should be carefully documented on the patient's record which medical personnel are responsible for the specimen from the time it was collected until the results are known.

The release of patients' records that pertain to chemical substance abuse is protected by federal laws under the Federal Drug Abuse Prevention, Treatment, and Rehabilitation Act. The law prohibits disclosure of information that identifies the patient as a chemi-cal substance abuser. Also, information about the patient's treatment cannot be divulged without the patient's written consent. The records can, however, be released by order of a subpoena to another health care professional during an emergency situation or if the records are to be used for research and program evaluation.

Changing societal values have contributed to an explosion of lawsuits in medical practice. Patients are more aware than ever of their rights, especially those of confidentiality and the right to privacy, consent, and records ownership. They readily seek redress when they perceive their rights to be violated. A healthy relationship between physicians and patients and between medical assistants and patients, as well as respect for the patient's rights, lowers the potential for the likelihood of a lawsuit. Knowledge of the laws that regulate medical and business practices in your state are necessary in order to be in compliance. Sources of information regarding state and federal laws can be obtained from the state medical society, the physician's liability insurance company, the state medical assistant society, the state attorney general's office, or the public library.

Law And Health Professional

The law as it relates to health care has grown increasingly complex in the past decade. The agendas of federal and state governments include an investigation of quality health care, a desire to control health care costs (while hoping to assure equitable access to health care), and an interest in protecting the patient. A full discussion of health law requires several volumes; therefore, only the laws designated to protect the patient will be identified in this chapter, and emphasis will be placed on the ambulatory care setting.

For example, at the ambulatory care center of Doctors Lewis and King, a two-doctor family physician office, Dr. Lewis and Dr. King are especially careful about establishing stringent risk management procedures to protect patients from harm and the practice from potential liability. Dr. King has worked with office manager Marilyn Johnson, CMA to assemble a policy and procedures manual outlining everything from how telephone calls are answered to how patient medical records are documented and stored. Marilyn, in turn, seeks the input of the other administrative and clinical medical assistants as she frequently updates the manual. To ensure that they are providing the best care for patients while protecting themselves, four times a year the entire staff meets to review office policies, changing them as necessary or incorporating new procedures to meet new situations or legal mandates.

Being aware of the law and its implications and establishing sound practices and procedures will both safeguard patient rights and protect the health care professional.The most frequent law exercised in the ambulatory care setting is civil law, or law as it is related to individuals. Restitution awarded when a civil wrong is committed is usually monetary in nature. Criminal law addresses wrongs committed against the welfare and safety of society as a whole and punishment is usually imprisonment or a fine.

If a charge is brought against a physician as the defendant in a civil case, the goal is to reimburse the plaintiff, the person bringing charges (usually a patient), a monetary amount for suffering, pain, and any loss of wages. For example, a physician who has caused harm to a patient in the course of treatment may be sued in a civil case by the patient for the recovery of time lost from work as well as the pain and suffering that was the result of treatment.In a criminal case, charges are brought against the defendant by the state with the intent of preventing any further harm to society. For example, a physician practicing medicine without a proper license may be subject to disciplinary action from a professional association and criminal action by the courts.

Goal Setting For Medical Assistants

Discoveries prove that goal-oriented employees are more effective and assertive than colleagues with no goals or future objectives. Recognizing the value of goal planning, many employers arrange planning sessions and/or seminars to encourage goal setting as a practical application for coping with stress and the development of career objectives. If this does not happen in your work environment, seek your own seminars for goal setting. Such an activity not only "centers" you in your current employment but helps you clearly picture your future plans and hopes.

What is a goal? The dictionary definition of a goal according to Websters Collegiate Dictionary is, "the result or achievement toward which effort is directed." In order to reach a desired goal, a person must implement planning along with a sincere desire to work hard. Skill in goal setting allows the medical assistant to clarify what must be accomplished and to develop a strategic plan to successfully achieve the goal. A goal must be specific, challenging, realistic, attainable, and measurable. Specific goals are focused and have very precise boundaries. A goal that is challenging creates enthusiasm and interest in achievement. Realistic goals are practical or beneficial for the present and for future self-actualization. An attainable goal refers to the fact that the goal is possible to fulfill. Measurable goals achieve some form of progress or success. By reflecting back on the process, one is encouraged to establish additional goals.

Long-range goals are achievements that may take three to five years to accomplish. Long-range goals give direction and definition to our lives and serve to keep us "on track" so to speak. Much discipline, perseverance, determination, and hard work will be expended in accomplishing long-range goals. Some adjustment and readjustment to your goals may be necessary, however. The rewards of goal achievement include satisfaction, pride, a sense of accomplishment, and a job well done.    

Short-range goals take apart long-range goals and reassemble the required activities into smaller, more manageable time segments. The time segments may be daily, weekly, monthly, quarterly, or yearly periods.    

As a graduate and new employee, one of your long-range goals might be to become the office manager in the ambulatory care setting in which you are currently employed. You may wish to attain this goal within the next three to five years; by breaking it into three longer range goals and a series of short-range goals, you will be able to measure progress and feel a sense of accomplishment. Examples of long- and short-range goals might include:    

Long-range goal #1:    
To become proficient in all back-office clinical skills during the first year of employment!
Short-range goals necessary to achieve this goal # 1:
a) Practice accuracy and proficiency when performing tasks and skills.    
b) Practice efficiency by planning ahead for the equipment and supplies needed for each task performed.    
c) Evaluate your progress on a regular basis and identify areas that need improvement.    

Long-range goal #2:    
To add front-office administrative tasks and skills to your routine during the second year of employment.    
Short-range goals necessary to achieve this:
a) Practice accuracy and proficiency when performing all front-office tasks and skills.
b) Practice efficiency by planning ahead for the equipment and supplies needed for each task performed.    
c) Evaluate your progress on a regular basis and identify areas that need improvement.

Long-range goal #3:
To begin to focus on office management during the third year of employment.    
Short-range goals necessary to achieve this:    
a) Develop a procedures manual for all back- and front-office tasks and skills.    
b) Enroll in office management classes.    
c) Focus on team-building skills.    

By year four, you will be ready to move into the office manager position.    
Long-range and short-range goals work together to help make changes in our lives. Goals keep life interesting and give us something to strive for. We can all reach goals successfully with some planning, hard work, discipline, and dedication.

Few Issues For Contemplation And Discussion

Medical assistants will encounter ethical and bioethical issues across the lifespan. A few issues are identified for contemplation and discussion. Issues of bioethics common to every medical office are the allocation of scarce medical resources,

In premature, deformed, or severely disabled babies, ethical issues include the decision to provide or withhold treatment. Health care professionals and parents are not always in agreement. Central to this issue, also, is the expense involved in certain treatments and deciding who pays the cost of treatment.    
Vulnerability of infants can lead to issues of negligence, abuse, or rejection. Parents are vulnerable too, for often they may not understand the ramifications of certain decisions about care of family members. Sometimes these decisions can lead to hundreds of thousands of dollars in medical expenses. Parents are also vulnerable because they may be unable to cope with the needs of the entire family.    

Children who are ill-fed, housed, educated, and clothed exhibit great needs for preventive, curative, and rehabilitative health care.    
Minors with sexually transmitted diseases often seek treatment without the parents' knowledge; they can be treated without parents' consent. Treatment also must be offered without parental consent to pregnant, infected, or addicted minors. Some health care professionals consider this an ethical issue and a violation of parents' rights. Child abuse presents an ethical dilemma, especially when a child confides physical, sexual, or emotional abuse to a health care worker but does not want the information divulged. Health care professionals, as mandated reporters, must report suspected child abuse. Will the child/patient view this as a violation of confidence or suffer dire consequences as a result of the reported abuse?    


Adolescents as young as thirteen- to eighteen-years-old may seek abortion without parental knowledge or consent. Is this a violation of parents' right to medical information regarding their children? Or should the adolescent, fearful of parental reaction, have the right to decide? The adolescent's growing autonomy, need for independence, changing values, and desire for peer acceptance lead to a number of ethical issues that may involve the health care environment.

Adults are increasingly faced with loss of jobs because of downsizing and layoffs. Previously with job loss, health care benefits could be lost. In August 1996, the Health Insurance Reform Act (Kassebaum-Kennedy Bill) was adopted. Among other things, this Act helps limit preexisting conditions and assures availability of individual policies for those who leave jobs voluntarily or involuntarily.    
Many low-income women do not have sufficient access to prenatal care, which has proven to be a cost-saving medical measure that is critical to the health of both mother and infant. As employers seek to reduce the cost of health insurance benefit programs, many individuals and families are finding themselves shifted from one insurance program to another, leaving them with little or no continuity of care. Also, in some managed care programs, adults may receive medical services from a number of health care professionals with whom they have no opportunity to establish an ongoing physician-patient relationship. Even with a physician's directive or a living will, a dying patient's wishes may not be followed. Technological advances in medicine have created a situation where patients may not be able to exercise a choice in the death issue even in states that may allow physician-assisted suicide.

Senior Adults:
Dementia is a common problem that is physically and financially exhausting for the caregiver, who is usually a spouse or adult child. How do caregivers cope with their own needs and the needs of dependent adults? Decisions about how and where to provide care for the senior adult pose ethical dilemmas with no easy answers. Often, the elderly may reject nursing home placement, and there may be limited funds for such long-term care. Elderly patients have the right to maintain dignity and privacy, but often their dependency on others deprives them of these basic rights. Physician-assisted suicide for terminally ill patients is a prominent issue in our society, especially when elderly patients sense a total loss of dignity. Such a decision, however, is never easily made.    

Contract between Patient and Medical Assistant

A contract is a binding agreement between two or more persons. A physician has a legal obligation, or duty, to care for a patient under the principles of contract law. The agreement must be between competent persons to do or not to do something lawful in exchange for a payment. A contract exists when the patient arrives for treatment and the physician accepts the patient by providing treatment. An example of a valid contract occurs when a patient calls the office or clinic to make an appointment for an annual physical examination. Assuming both physician and patient are competent and that the physician performs the lawful act of the physical examination and the patient pays a fee, all aspects of the contract exist.

There are two types of contracts, expressed and implied. An expressed contract can be written or verbal and will specifically describe what each party in the contract will do. A written contract requires that all necessary aspects of the agreement be in writing. An implied contract is indicated by actions rather than by words. The majority of physician-patient contracts are implied contracts. It is not required that the contract be written to be enforceable as long as all points of the contract exist. An implied contract can exist either by the circumstances of the situation or by the law. When a patient complains of a sore throat and the physician does a throat culture to diagnose and treat the ailment, an implied contract exists by the circumstances. An implied contract by law exists when a patient goes into anaphylactic shock and the physician administers epinephrine to counteract shock symptoms. The law says that the physician did what the patient would have requested had there been an expressed contract.    

For a contract to be valid and binding, the parties who enter into it must be competent; therefore, the mentally incompetent, the legally insane, persons under heavy drug or alcohol influences, infants, and some minors cannot enter into a binding contract. Medical assistants are considered agents of the physicians they serve and as such must be cautious that their actions and words may become binding on their physicians. For example, to say that the doctor can cure the patient may cause serious legal problems when in fact a cure may not be possible.

Termination of Contracts:
A broken contract or breach of contract occurs when one of the parties does not meet contractual obligations. A physician is legally bound to treat a patient until:
1) the patient discharges the physician    
2) the physician formally withdraws from patient care    
3) the patient no longer needs treatment and is formally discharged by the physician    

Common Torts And How to Avoid Them

Some specific examples of common torts that can occur in the office or clinic are battery, defamation of character, and invasion of privacy.    

1) Battery:
The basis of the tort of battery is unprivileged touching of one person by another. A patient must consent to being touched. When a procedure is to be performed on a patient, the patient must give consent in full knowledge of all the facts. It does not matter whether the procedure that constitutes the battery improves the patient's health. Patients have the right to withdraw consent at any time.
One example of battery is when a medical assistant insists on giving the patient an injection the physician ordered for the patient even though the patient refuses the injection. Another example can be seen when a physician performs additional surgery beyond the original procedure (the surgeon performed a hysterectomy for which consent was given, but is liable for battery for removing an abdominal nevus from the patient's abdomen without consent). It does not matter that the physician does not charge for the additional procedure. It also does not matter if the patient would have given consent if asked in advance.    

2) Defamation of Character:
The tort of defamation of character consists of injury to another person's reputation, name, or character through spoken or written words for which damages can be recovered. Two kinds of defamation are libel and slander. Libel is false and malicious writing about another such as in published materials, pictures, and media. An example can be seen when the medical assistant writes in the patient's record, "Mr. O'Keefe's wife appears to be the cause of his ulcer." A copy of Mr. O'Keefe's records were later sent to a new physician who reviewed the record and saw the remarks quoted by the medical assistant.
Slander is false and malicious spoken words. Slander can be seen in the following comment directed by a patient toward the physician, "Dr. Woo is incompetent. He should have his license revoked." The statement is overheard by the office receptionist and other patients waiting in the reception area. In order for a tort of defamation of character (either libel or slander) to exist, a third party must see or hear the words and understand their meaning.    

3)Invasion of Privacy:

Invasion of privacy is another kind of tort. It includes unauthorized publicity of patient information, medical records being released without the patient's knowledge and permission, and patients receiving unwanted publicity and exposure to public view. For example, if a minor unmarried girl has been examined for possible pregnancy, and the medical assistant telephones the laboratory report to the girl's home and inadvertently gives the results to someone other than the patient, her privacy has been invaded. A second situation exists when persons other than those providing care and performing examinations and procedures (essential or nonessential personnel) are allowed to be present without the patient's consent. Yet another example is that the patient's right to privacy has been violated when asked to walk from the examination room across the hall to a treatment room while wearing only a patient gown in full view of other patients and personnel.    

Medical assistants and other health care professionals should:    

a)  close a door, pull a curtain, or provide a screen when looking at, handling, or examining the patient's body
b) expose only body parts necessary for treatment (drape the patient's body, exposing only that part which is being treated)    
c)discuss patients with no one except those individuals involved in the patient's care and then discuss only those aspects that relate to the needs of the patient for care
It is not an invasion of privacy to disclose information required by a court order (subpoena) or by statute to protect the public health and welfare as in the reporting of violent crime.

Ethics And Bioethics For Medical Assistants

It is impossible in today's world to function as a medical assistant without an awareness of the impact of ethics and bioethics on health care. Just as an understanding of the law and working within the law is vital information for the medical assistant, it is equally important to understand ethics and bioethics. From the previous blogposts, you have come to realize that there are many circumstances and situations that occur in health care that are guided and directed by state and federal laws. You, personally, are expected to be above reproach in all your actions in this regard.

You must also work with your employer and other members of the health care team to assure that each member of the staff functions within the law protecting both patients and providers. Ethics plays a huge role in such an endeavor. To function ethically demands that you never function outside the law. Ethics, however, demands something  calls for honesty, trustworthiness, integrity, confidentiality, and fairness. To function ethically, you must know yourself well and understand weaknesses and any vulnerabilities that might prevent you from acting ethically.

On occasion, ethical dilemmas occur because patients are unsure of the role of the medical assistant. For example, the medical assistants of Inner City Health Care are truly multidisciplinary and have a range of administrative and clinical skills. However, patients sometimes think of them as nurses who have an entirely different set of skills. While most of the medical assistants gently correct patients and make it a point to practice only within their area of expertise, occasionally newer members of the medical assistant staff may feel more "important" when patients regard them as nurses or physicians' assistants. This is just one situation in which medical assistants may need to reflect on their actions and be sure that they are acting ethically and within the range of their skills. Medical assistants also need to recognize the warning signs that they, or some other staff member, may be about to breach a code of ethics. Often, this kind of breach occurs when one has, or seeks to have, too much power; when one attempts to take too much authority; and when one has too little knowledge and experience. When a breach seems about to occur, the individuals involved should be encouraged to step back and review their actions and the likely consequences of those actions.

Traditionally, ethics has been defined in terms of what is right or wrong. For health care professionals, ethics is often defined by a code or creed as seen in the Code of Ethics from the American Association of Medical Assistants (AAMA) or the Principles of Medical Ethics from the American Medical Association (AMA). While these codes, and many others like them, are essential and very helpful, they lose their vitality unless they are understood by individuals who possess a personal and sound moral code or set of values. Unlike the law, which seldom changes unless challenged and examined in the courts, codes of ethics constantly change and evolve just as personal values and morals change and evolve. Every time values are challenged and examined, a medical assistant's personal ethical codes become stronger, the understanding of others' perceptions becomes clearer, and professionalism is enhanced.


Bioethics brings the entire focus of ethics into the field of health care and into those ethical issues dealing with life. Never before in the history of medical care has bioethics been such a topic of concern. In the past, most bioethical decisions were made by physicians and esteemed members of the medical and/or legal profession. However, advancing technology giving patients and consumers numerous choices regarding their health care causes each one of medical assistants to take an active role in bioethics.

Medical Practice Acts and Medical Assistant's Role

Each state has medical practice acts that regulate the practice of medicine with the intent of protecting its citizens from harm. These statutes, or laws, govern licensure, standards of care, professional liability and negligence, confidentiality, and torts. Some states also regulate personnel who may be employed in the ambulatory care setting. For example, some states require that medical assistants be licensed or certified to be able to perform any invasive procedures. Other states require additional training in radiology for the medical assistant to be able to take X-rays. Further, some states are so strict in their regulations that medical assistants perform mostly clerical functions. Certainly, medical assistants desiring to utilize their skills must be aware of state regulations and always perform only within the scope of those regulations.

The Patient's Bill of Rights was developed by the American Hospital Association in 1973 to establish more effective patient care and greater satisfaction for patient, physician, and hospital. While this Bill of Rights was written with the hospital patient in mind, patients in ambulatory care settings should be accorded the same rights. Although no list of rights can guarantee the kind of treatment patients have a right to expect, medical assistants should make every effort to conduct activities with the concern of the patient in mind. here are a number of ways in which the law governs physicians and their employees. Some of these issues are particularly pertinent to the ambulatory care setting and the medical assistants who work in these health care environments.


a) The patient has the right to considerate and respectful care.
b) The patient has the right to obtain from his physician complete current information concerning his diagnosis, treatment, and prognosis in terms the patient can be reasonably expected to understand.
c) The patient has the right to receive from his physician information necessary to give informed consent prior to the start of any procedure and/or treatment. Except in emergencies, such information for informed consent should include but not necessarily be limited to the specific procedure and/or treatment, the medically significant risks involved, and the probable duration of incapacitation.
d) The patient has the right to refuse treatment to the extent permitted by law, and to be informed of the medical consequences of his action.    
e) The patient has the right to every consideration of his privacy concerning his own medical care program. Case discussion, consultation, examination, and treatment are confidential and should be conducted discreetly. Those not directly involved in his care must have the permission of the patient to be present.    
f) The patient has the right to expect that all communications and records pertaining to his care should be treated as confidential.
g) The patient has the right to examine and receive an explanation of his bill regardless of source of payment.
h) The patient has the right to know what hospital rules and regulations apply to his conduct as a patient.

AMA Ethical Guidelines

The American Medical Association and its nine-member Judicial Council publish a guide for ethical behavior for physicians that is beneficial to medical assistants who act in concert with their physician/employer. The guidelines are based on the publication Code of Medical Ethics Current Opinions of the Council on Ethical and Judicial Affairs of the American Medical Association, 1992. Information shared here is not meant to be exhaustive; however, physicians and their employees will find it helpful to consider information on the following topics, which was summarized from this publication. The complete guide can be purchased from AMA office in Chicago, IL. See Appendix A for the address and phone number.    

Physicians and professional people have traditionally not advertised; however, it is not illegal to do so if claims made are truthful and not misleading. Advertisements may include credentials of physicians and a description of the practice and kinds of services rendered. Testimonials from patients are best avoided. Indeed, most physicians discover that word-of-mouth advertisement from patients is the best source of advertisement for their practice.    

Media Relations
Physicians and all of their employees are not allowed to discuss a patient's medical condition with any member of the media without the patient's expressed approval. This does not apply to informa-tion that is considered ''public domain," which includes births, deaths, accidents, and police records.While more hospitals than ambulatory care settings will be involved in media relations, the following is an example of information released that is considered public domain and does not require the patient's consent.


Physicians must not reveal confidential information about patients without their consent unless they are otherwise required to do so by law. Confidentiality must be protected so that patients will feel comfortable and safe in revealing information about themselves that may be important to their health care. The following list contains examples of the kinds of reports that allow or require health professionals to report a confidence.    
1) A patient threatens another person and there is reason to believe that the threat may be carried out.    
2) Reportable injuries and illnesses must be reported. They include injuries such as knife and gunshot wounds, wounds that may be from suspected child abuse, and communicable diseases such as influenza, AIDS, and sexually transmitted diseases.    
3) Information that may have been subpoenaed for testimony in a court of law.    
When in doubt, it is always recommended that a physician have the patient's permission to reveal any confidential information.

Medical Records

The medical chart and the information in it are the property of the physician and the patient. No information should be revealed without the patient's consent unless required by law. The record is confidential. Physicians should not refuse to provide a copy of the record to another physician treating the patient so long as proper authorization has been received from the patient. A record cannot be withheld because of an unpaid bill.    
Upon a physician's retirement or death, or when a practice is sold, patients should be notified and given ample time to have their records transferred to another physician of their choice.

Professional Fees and Charges
Illegal or excessive fees should not be charged. Fees should be based on those customary to the locale and should reflect the difficulty of services and the quality of performance rendered. Fee splitting (a physician splits the fee with another physician for services rendered with or without the patient's knowledge) in any form is unethical. Physicians may charge for missed appointments (if patients have first been notified of the practice) and may charge for multiple or very complex insurance forms. Physicians and their employees must be diligent to assure that only the services actually rendered are charged or indicated on the insurance claim. Only what is documented in the patient's chart is to be billed.

Coping With Stress For Medical Assistants

When too much stress is experienced or if the stress lasts for a long period of time, it begins to affect the body in a negative way. Often one of the first signs of stress may be a headache caused by an increase in blood pressure. Feeling tired even after plenty of rest may be another signal of stress. If these conditions continue, other vital organs, such as the heart and lungs for example, may also be affected negatively. They can use Watercolor Pencils but Cardiac or respiratory arrest, transient ischemic attack, or fainting may be experienced.    

For the medical assistant, new technology, a demanding work load, responding to the needs of persons who are ill or hurting, patients very diverse in culture, and the continuing need for creative problem solving are examples of the stressors encountered daily in ambulatory care settings.

Coping with Stress:

The following suggestions may be helpful in coping with stressors in the work environment.    
1. Plan ahead    
a) Review the schedule for the next day and pull charts before leaving the office for the day.
b) Keep an accurate inventory of supplies; order before the last items are used.
c) Read journals and keep current with new technology.    
d) Participate in continuing education activities.    
2. Arrive early    
a) Review the patient charts for the day; notice any special problems or needs.    
b) Be sure that each exam room is well-equipped and ready for patients.    
3. Personal assessment    
a) Get plenty of rest.    
b) Exercise and eat balanced meals.    
c) Dress appropriately. Clothing or shoes that are too tight cause stress.    
4. Laugh    
a) Learn to laugh at life's little problems.    
b) Laugh at yourself.    
c) Establish an appropriate level of humor with other members of the staff.    
5. Music/Color/Light    
a) Soft background music has been proven to soothe and promote relaxation.    
b) Use color and light to create a calm atmosphere.

6. Breaks
a) Build morning and afternoon breaks into the schedule, even if only five or ten minutes.    
b) Close the office during the lunch hour, and if possible, leave the facility.

7. Work smarter, not harder
a) Employ time management techniques for reducing stress by completing one task before moving on to another.
b) Prioritize tasks; when possible doing the most difficult task early in the day.    
c) Do not procrastinate.    
d) Be motivated.    
e) Be a team member as well as working well independently.    
f)  Plan your work, then work your plan.

Burnout And Medical Assistants

The term currently used to describe a kind of stress-related energy depletion that takes place in the working world is burnout (Wilkes & Crosswait, 1991). Burnout exhausts one's physical and mental resources, and leaves one feeling angry, helpless, and trapped. The military term for burnout is "battle fatigue." As a medical assistant, you are a member of the health care team that battles disease and the ravages of disease on a daily basis.    

Burnout does not occur suddenly as does stress. Rather it is a gradual process that occurs slowly over a period of time. Typical signs and symptoms of burnout include:
1) Chronic fatigue
2) Anger    
3) Self-criticism    
4) Irritability    
5) Hair-trigger display of emotions    
6) A sense of being constantly under attack    
7) Inability to keep even daily frustrations in perspective    

Some individuals cope by developing negative work attitudes such as being critical, hard to get along with, or having a lack of motivation and a poor personal appearance and hygiene. These attitudes may lead to burnout. When some medical assistants with a high need to achieve and having no pencil sharpener electric
do not often reach their goals, they are apt to feel angry and frustrated. Failing to recognize these signs as symptoms of burnout, the person may throw themselves even more fully into work-related goals. Unless there is some type of revitalization outside of the workplace, burnout occurs.    

According to industrial psychologist Harry Levinson, the following aspects of personality promote burnout:    
1) A higher need to do a job well for its own sake then do most of one's peers
2) A greater need for achievement
3) More motivation to dominate and lead than peers    
4) Less motivation to defer to authority    
5) An intense need to achieve one's goals (Wilkes & Crosswait, 1991)    
Preventing Burnout
The best way to treat burnout on the job is to prevent it. This can be accomplished by leaving work-related issues at the office when leaving for the day and study the real causes of divorce. Other things a medical assistant can do to reduce the risk of burnout include:    

1) Maintain a positive self-esteem and self-image
2) Have regular physical examinations
3) Take a vacation    
4) Give up unrealistic goals and expectations    
5) Develop interests outside of your profession    
6) Separate work from the rest of your life    
7) Develop time management techniques