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MO 260 Unit Two Clinical Skills for the Medical Office Manager Agenda ◦ Review Unit One ◦ Overview Unit Two ◦ Discussion/Presentation Discussion Board-Good Samaritan Laws (1st choice) Seminar Discussion-Patient History Form/Medical Records Video Unit Two Activities/Readings Asepsis-Infection Control/OSHA/Biohazardous Waste Prepping Patient Exam Room Obtaining Patient Vital Signs In-House Emergencies ◦ Questions weekly deliverables ?? Let’s Review • • • • Patient Termination Professionalism License renewal-Physician & CMA/RMA Liability & HIPAA • www.youtube.com/watch?v=fTjZ7GokQw4 • The Patient Chart • Our Discussion Board Unit Two Discussion –Good Samaritan Seminar-Here we are! Assignment Assessment ◦ Activities Asepsis, Prep Pt Room, Basic Charting, Emergencies On the Discussion Board: Good Samaritan Laws STATEMENT This bill supplements the "Good Samaritan Act," P.L.1963, c.140 (C.2A:62A-1 et seq.) to clarify that the immunity from liability for civil damages afforded under that act extends to include municipal, county and State firefighters, both paid or volunteer, who render emergency assistance at the scene of an accident. Under common law, while a person is under no obligation to provide emergency assistance at the scene of an accident, a person who chooses to do so may be held civilly liable if he or she is found to have acted in a negligent manner. To encourage individuals to render assistance at accident scenes, New Jersey and many other states have adopted "Good Samaritan" acts to provide civil immunity for individuals who in good faith render emergency care at the scene of an accident or in an emergency. In its present form, New Jersey's "Good Samaritan Act" provides immunity to (1) any individual, including health care professionals; (2) the members of volunteer first aid, rescue and ambulance squads and (3) municipal, county and State law enforcement officers, who in good faith render emergency care at the scene of an accident or in an emergency or who, in the case of volunteer members or first aid, rescue and ambulance squads, transport the victims of an accident or emergency to a hospital or other facility for treatment. This bill would add municipal, county and State firefighters, both paid and volunteer, to those specifically afforded immunity under the "Good Samaritan Act." Resource: http://www.njleg.state.nj.us/9899/Bills/a2500/2270_i1.pdf Medical History: Collecting the information Besides being useful for diagnosing and treating the patient, the self-history allows the patient more participation in the process. The form may be mailed to the patient’s home before the appointment or may be completed in the office during the first visit. If you are responsible for taking a portion of the medical history, conduct the interview in a private area free from outside interference and beyond the hearing range of other patients. Seminar Discussion The Importance of Medical Records http://youtu.be/TZzIw6RpQVg Aseptic Techniques: Prevention of Disease Transmission Medical asepsis. Surgical asepsis. Medical aseptic techniques: Create an environment as free of pathogens as possible to prevent reinfection or cross-infection. Surgical aseptic or sterile technique: Used when the patient’s skin or mucous membranes are disrupted. Prevents patient exposure to all microbes (e.g., for minor surgery, urinary catheterizations, injections). Asepsis: Removing pathogenic organisms or protecting against infection by these organisms Handwashing Sanitization Disinfection Sterilization OSHA Standards for Healthcare Workers Healthcare workers face significant health risks from occupational exposure to blood or other potentially infectious materials that may contain hepatitis B virus (HBV), hepatitis C virus (HCV), or the human immunodeficiency virus (HIV). The MA should use precautions for all patients, regardless of knowledge of their individual health histories. Implementation of the Bloodborne Pathogen Standard also protects patients from any bloodborne infection the healthcare worker may be carrying. Chain of Infection Infectious diseases can spread only if certain factors occur. These factors, or links, make up the chain of infection. Break the chain, and you break the infectious process. The chain begins with the infectious agent, which invades the reservoir host, and continues with the means or portal of exit from the host, the method of transmission, the means or portal of entry into a new host, and the presence of a susceptible host. Chain of Infection Transmission Direct—contact with infected person or with discharges (feces, urine, sputum, etc.) Indirect—from droplets expelled with coughing, sneezing, or speaking; vectors; contaminated food; contaminated objects called fomites. Controlled with sanitization, disinfection, sterilization, and so on Exposure Control Plan Plan must detail employee protection procedures. Must identify job classifications and/or specific work-related tasks that might lead to exposure. Must contain specifics on controls including PPE, training, hepatitis B immunization, record keeping, postexposure follow-up, and labeling and disposal of biohazard waste. Must be reviewed and updated at least annually to incorporate the use of safer medical devices. Must be available to employees for review and training. Biohazardous Waste Basic Charting Interviewing the patient ◦ Open ended/closed ended questions ◦ Documenting on the progress notes Soap notes: Subjective, Objective, Assessment and Plan ◦ Source Oriented/Problem Oriented Charts In-House Emergency Guidelines What is the office policy? What types of emergencies can occur in the medical office? Who is the decision maker? Who calls 911? What equipment should you have? Healthcare Provider CPR?