- Six rights of medication administration
- Right patient, right drug, right dose, right route, right time, and right documentation.
- Right documentation timing
- Chart the medication after it is given, never before administration.
- Two patient identifiers
- Verify identity with full name and date of birth — never room number or position alone.
- Generic drug name
- The official, non-proprietary name (lowercase), e.g., acetaminophen; one per drug.
- Brand (trade) drug name
- The manufacturer's marketed name (capitalized), e.g., Tylenol; one drug may have several.
- Intradermal (ID) angle
- 10–15° — just under the epidermis to form a wheal; TB (Mantoux) and allergy testing.
- Subcutaneous (SubQ) angle
- 45° (or 90° with a short needle) — into fatty tissue; insulin and heparin.
- Intramuscular (IM) angle
- 90° — straight into muscle for faster absorption and larger volumes; many vaccines.
- Oral (PO) route onset
- Generally the slowest onset of the common routes; absorbed through the GI tract.
- Adult IM injection sites
- Deltoid and ventrogluteal are preferred for adults.
- Infant IM injection site
- Vastus lateralis — a large thigh muscle with no major nerves or vessels nearby.
- Dosage calculation formula
- (Desired ÷ Have) × Quantity = amount to give.
- Metric: grams to milligrams
- 1 gram (g) = 1,000 milligrams (mg).
- Metric: milligrams to micrograms
- 1 milligram (mg) = 1,000 micrograms (mcg).
- Metric: liters to milliliters
- 1 liter (L) = 1,000 milliliters (mL).
- Sublingual (SL) route
- Medication placed under the tongue to dissolve and absorb rapidly (e.g., nitroglycerin).
- Analgesic
- A drug class that relieves pain (e.g., acetaminophen, ibuprofen, opioids).
- Antibiotic
- A drug class that treats bacterial infections; not effective against viruses.
- Antihypertensive
- A drug class that lowers high blood pressure.
- Anticoagulant
- A drug class that prevents blood clots (e.g., heparin, warfarin).
- Bronchodilator
- A drug class that relaxes airway muscles to ease breathing (e.g., albuterol).
- Antipyretic
- A drug class that reduces fever (e.g., acetaminophen).
- Diuretic
- A drug class that increases urine output to remove excess fluid.
- Root word cardi/o
- Means heart — e.g., cardiology is the study of the heart.
- Suffix -itis
- Means inflammation — e.g., carditis is inflammation of the heart.
- Suffix -ectomy
- Means surgical removal — e.g., appendectomy is removal of the appendix.
- Prefix hyper-
- Means excessive or above normal — e.g., hypertension is high blood pressure.
- Prefix hypo-
- Means below normal or deficient — e.g., hypoglycemia is low blood sugar.
- Normal adult pulse
- 60–100 beats per minute at rest.
- Normal adult respirations
- 12–20 breaths per minute at rest.
- Normal adult blood pressure
- Less than 120/80 mmHg.
- Normal oral temperature
- About 98.6 °F (37 °C); roughly 97.8–99.1 °F.
- Normal oxygen saturation (SpO₂)
- 95–100%.
- Allergy and the right-drug check
- A documented allergy means the right-drug check fails — do not give it; alert the provider.
- Standard Precautions
- Infection-prevention practices used for every patient; treat all blood and body fluids as infectious.
- Universal Precautions
- Earlier approach of treating all blood as infectious; combined with body substance isolation to form Standard Precautions.
- Contact precautions
- Gown and gloves for organisms spread by touch (MRSA, C. difficile, scabies).
- Droplet precautions
- Surgical mask within close range for large respiratory droplets (influenza, pertussis, mumps).
- Airborne precautions
- N95 respirator and negative-pressure room for droplet nuclei (tuberculosis, measles, varicella).
- C. difficile hand hygiene
- Use soap and water — alcohol-based gel does not kill spores.
- Most effective infection-control measure
- Hand hygiene — the single best way to prevent health-care-associated infection.
- Medical asepsis
- Clean technique that reduces microorganisms (hand washing, disinfection).
- Surgical asepsis
- Sterile technique that eliminates all microorganisms for invasive procedures.
- Order of donning PPE
- Gown, then mask/respirator, then goggles/face shield, then gloves.
- Order of draw (CLSI)
- Blood cultures, light-blue, red/gold serum, green, lavender, gray — prevents additive carryover.
- Light-blue tube
- Sodium citrate — coagulation studies (PT/INR, PTT); must be filled completely.
- Red/gold (SST) tube
- Clot activator/gel — serum chemistry and serology.
- Green tube
- Heparin — plasma and STAT chemistries.
- Lavender tube
- EDTA — hematology/CBC; preserves cell morphology by binding calcium.
- Gray tube
- Sodium fluoride/potassium oxalate — glucose and lactate; preserves glucose.
- Preferred venipuncture site
- The median cubital vein in the antecubital area.
- Specimen labeling rule
- Label at the bedside, immediately after collection, in the patient's presence.
- Needlestick first step
- Wash the site with soap and water, then report it under the OSHA exposure plan.
- Recapping needles
- Never recap by hand; activate the safety device and dispose in a sharps container.
- Sharps disposal
- Dispose at the point of use in a puncture-resistant, leak-proof container.
- CLIA-waived test
- A simple test cleared for use outside a high-complexity lab (e.g., glucose, rapid strep, urinalysis).
- Point-of-care testing (POCT)
- Diagnostic testing performed near the patient for rapid results.
- Standard ECG leads
- 12-lead: four limb leads plus six chest (precordial) leads.
- ECG lead placement importance
- Misplaced leads create artifact that can mimic or mask real findings.
- MA role in ECG
- Record the tracing accurately; the provider interprets it.
- Blood pressure cuff too small
- Falsely raises the reading.
- Blood pressure cuff too large
- Falsely lowers the reading.
- Correct BP technique
- Patient seated 5 min, back supported, feet flat, arm at heart level, no talking.
- Korotkoff sounds
- The sounds heard during BP measurement; first = systolic, last = diastolic.
- Apical pulse
- Pulse taken with a stethoscope at the apex of the heart; most accurate for irregular rhythms.
- Wound care principle
- Clean from the center outward and keep the field as clean (or sterile) as the procedure requires.
- Autoclave
- Uses pressurized steam to sterilize instruments — kills all microorganisms including spores.
- Sterile field rule
- Keep items above the waist; anything below the waist or out of sight is considered contaminated.
- Fowler's position
- Sitting/semi-sitting position used for patients with breathing difficulty.
- Supine position
- Lying flat on the back, face up.
- Prone position
- Lying flat on the abdomen, face down.
- Capillary puncture site (adult)
- The side of the fingertip (3rd or 4th finger).
- Heel stick site
- Used for capillary blood collection in infants.
- Tourniquet time limit
- No more than 1 minute, to avoid hemoconcentration and inaccurate results.
- Gauge of a needle
- The diameter — a higher gauge number means a thinner needle.
- ICD-10-CM code
- Reports the diagnosis — why the service was provided.
- CPT code
- Current Procedural Terminology — reports the procedure or service performed.
- HCPCS codes
- Cover items and services not in CPT (e.g., supplies, durable medical equipment).
- Medical necessity rule
- The diagnosis (ICD-10-CM) must support the procedure (CPT) or the claim may be denied.
- CMS-1500 form
- The standard claim form for billing professional (provider) services.
- Prior authorization
- A payer's advance approval that a service is medically necessary and covered, obtained before the service.
- No authorization on file
- A common denial when a required prior authorization was not obtained beforehand.
- Pre-certification
- Usually refers to advance approval of an inpatient admission or hospital stay.
- Expedited authorization
- A faster review available for urgent services.
- Correcting a record error
- Draw a single line through it, initial and date; never erase or obscure the original.
- EOB / ERA
- Explanation of benefits / electronic remittance advice — shows how a claim was paid.
- Copayment
- A fixed amount the patient pays per visit or service.
- Deductible
- The amount a patient pays before insurance begins to pay.
- Coinsurance
- A percentage of the cost the patient shares after the deductible is met.
- Clean claim
- A claim with no errors that processes without rejection.
- Wave scheduling
- Several patients booked at the start of each hour, seen as they become available.
- Modified-wave scheduling
- A blend that books patients at intervals within the hour to smooth flow.
- Encounter form / superbill
- Captures the diagnoses and services for a visit to drive coding and billing.
- Accounts receivable
- Money owed to the practice for services already provided.
- CHEDDAR / SOAP note
- Documentation formats for the clinical record (SOAP = Subjective, Objective, Assessment, Plan).
- Telephone screening rule
- Verify the caller's identity before disclosing any patient information.
- Inventory control
- Tracking and reordering supplies so the office never runs out of essentials.
- Daysheet
- A daily record of charges, payments, and adjustments.
- Aging report
- Shows how long claims or patient balances have been outstanding.
- Capitation
- A set per-member payment to a provider regardless of services used.
- HIPAA Privacy Rule
- Protects patients' protected health information from use or disclosure without authorization.
- Protected health information (PHI)
- Individually identifiable health information protected under HIPAA.
- Treatment, payment & operations (TPO)
- Uses/disclosures of PHI allowed without separate authorization.
- Minimum necessary standard
- Disclose only the least PHI needed for the purpose.
- Informed consent
- Voluntary agreement after being told the nature, risks, benefits, and alternatives.
- Implied consent
- Consent presumed in a true emergency when the patient cannot communicate.
- Provider's role in consent
- The provider obtains informed consent; the MA may witness the signature.
- Scope of practice
- The duties an MA is legally allowed to perform, set by state law and delegated by the provider.
- Negligence
- Failing to provide the standard of care, resulting in patient harm.
- Standard of care
- The level of care a reasonably prudent, similarly trained professional would provide.
- Advance directive
- A legal document recording treatment wishes or naming a decision-maker for future incapacity.
- Living will
- States the patient's own wishes about treatment if they cannot speak for themselves.
- Durable power of attorney for health care
- Names a person (proxy) to make medical decisions for the patient.
- Revoking a directive
- A competent adult may revoke or revise an advance directive at any time.
- DNR order
- Do Not Resuscitate — directs that CPR not be performed if the heart or breathing stops.
- Mandatory reporting
- Suspected child/elder abuse and certain diseases or injuries must be reported by law.
- Battery
- Touching a patient without consent.
- Assault
- The threat of harmful or offensive contact.
- Beneficence
- Acting in the patient's best interest.
- Nonmaleficence
- Do no harm.
- Autonomy
- Respecting the patient's right to make their own decisions.
- Confidentiality
- Keeping patient information private and disclosing only as permitted.
- Subpoena vs. court order
- A valid court order can compel record disclosure; follow office policy and verify it.
- Statute of limitations
- The legal time limit for filing a lawsuit.
- Respondeat superior
- An employer may be liable for an employee's actions performed within their job duties.
- Patient's Bill of Rights
- Outlines patient rights to information, privacy, respectful care, and informed decisions.
- Abandonment
- Stopping care of a patient without proper notice or transfer of care.