Overview
These notes outline key medical assisting procedures and foundational clinical knowledge, focusing on vital sign measurement, patient safety, medication administration, specimen collection, infection control, and essential anatomy. The document is intended as a practical guide for clinical staff.
Infection Control & PPE
- Always perform hand hygiene before and after patient contact and procedures.
- Wear PPE (gown, mask/respirator, goggles/face shield, gloves) per precautions required.
- Remove PPE in correct sequence to avoid self-contamination, ending with hand hygiene.
- Clean and disinfect reusable medical equipment after use.
Patient Preparation & Safety
- Use two identifiers to verify patient identity before procedures.
- Explain all procedures to patients in understandable terms and obtain consent.
- Display compassion during sensitive tasks (e.g., weight measurement).
- Ensure safety for all measurements; assist as needed to prevent falls or injury.
Vital Signs Measurement
- Measure weight and height with shoes/coats removed; document in EHR.
- Take temperature via oral, axillary, tympanic, or temporal methods appropriate to patient.
- Assess pulse at radial or apical sites, noting rate, rhythm, volume, and document findings.
- Observe respirations discreetly for 30–60 seconds; note rate, rhythm, and depth.
- Measure blood pressure with properly sized cuff, reporting both systolic and diastolic values.
- Use pulse oximetry on clean, polish-free fingers or earlobes; normal SpO₂ is ≥95%.
- Share abnormal results with provider immediately.
Medication Administration
- Wash/sanitize hands before and after medication administration.
- Perform triple medication check (when grabbing, preparing, disposing/returning med).
- Verify the “Seven Rights”: patient, drug, dose, route, time, technique, documentation.
- Use correct technique for all injection types (intradermal, subcutaneous, IM).
- Document lot number, expiration, site, and patient response after administration.
Specimen Collection
- Use proper PPE for collection (throat, urine, fecal, blood).
- Label all specimen containers with patient info, date, and time.
- Prevent cross-contamination; dispose of sharps and biohazard waste properly.
- Follow specific instructions for clean-catch, 24-hour urine, or sensitive pediatric tests.
Emergency Procedures & First Aid
- For seizures: ensure safety, place patient in recovery position, monitor, and document episode.
- For choking: perform abdominal thrusts, start CPR if unresponsive.
- For fainting/shock: position patient safely, elevate legs, monitor, notify provider.
- For bleeding: apply direct pressure, bandage, elevate limb, alert provider if uncontrolled.
Clinical Skills & Equipment Use
- Follow strict sterilization protocols for instruments.
- Prepare exam room and equipment for each patient.
- Accurately document all procedures, findings, and patient responses in the EHR.
Anatomy & Clinical Knowledge Essentials
- Understand the locations of main pulse points and arteries for measurement.
- Know definitions and normal ranges for vital signs by age group.
- Grasp the basics of pharmacokinetics and pharmacodynamics (absorption, distribution, metabolism, excretion, drug effects).
- Recognize common terminology and procedures in clinical practice.
Action Items
- Immediate – Clinical Staff: Ensure all equipment is calibrated and PPE supplies are stocked.
- TBD – All Staff: Review emergency protocols and vital sign measurement skills.
- Ongoing – Providers: Monitor EHR documentation accuracy for all patient measurements and interventions.