Foundational Knowledge and Basic Science: Health Care Systems and Settings

Health Care Systems and Settings

The medical field can seem overwhelming. New terminology, legal concerns, direct or
indirect patient care, unique processes, and high expectations can contribute to initial
apprehension. However, this new role can be better understood through a holistic
approach, looking at the health care system from all sides. In addition to understanding
the role and scope of practice, it is crucial to understand the importance of the entire
health care team. Knowing the skills and responsibilities of the various allied health and
specialty providers strengthens the effectiveness and cohesiveness of the health care
team. Each team member needs to respect and assist others in providing the best
possible care for the patient.

Medical Assistant Roles, Responsibilities, Scope of Practice, and Titles

MA Roles
The role of an MA is primarily to work alongside a provider in an outpatient or
ambulatory health care setting, such as a medical office. The MA can be cross-trained to
perform both administrative and clinical duties. Administrative duties include greeting
patients, scheduling, handling correspondence, and answering telephones. In addition,
the MA is often responsible for obtaining medical histories from patients, providing
patient education, performing laboratory tests, and preparing and administering
immunizations. An MA achieves credentialing by passing a national certification exam.
MA Responsibilities
The responsibilities of an MA vary based on the setting in which they work. Duties can
be primarily administrative, clinical, or a combination.
Administrative Duties

• Scheduling patient appointments

• Patient registration (demographics, payer information, compliance forms)

• Updating and working in patient records

• Sending claims to insurance

• Collecting patient responsibility amounts (copays, coinsurance, deductible)

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Clinical Duties

• Collecting and processing lab specimens

• Performing diagnostic testing (EKG, spirometry)

• Preparing and cleaning examination rooms

• Preparing the patient for evaluation and procedure

• Measuring vital signs

• Preparing medications and administering immunizations

The medical assistant’s role is constantly changing and evolving. In addition to
traditional responsibilities, medical assistants are doing more patient navigation and
care coordination work. In this role, medical assistants can guide patients as they
journey through the health care system—helping them understand what is happening
and what steps they need to take and helping them connect to the right specialists. To
effectively support the patient in this way, the MA will often need to coordinate with
other members of the patient care team, both within the clinic and externally with
specialty care teams. The MA may ask questions on the patient’s behalf to nurses and
providers within the team to better understand the plan of care and provide the
information to the patient in a clear, easily understood way. When coordinating with
other teams, medical assistants can provide helpful context about the patient’s social
determinants of health and barriers to care, as well as support the patient in being
scheduled appropriately and in a timely manner with specialists.
Scope of Practice
Scope of practice describes the duties delegated based on education, training, and
experience. The scope of practice for the MA does not include the practice of
medicine. Medical assistants should not perform duties they have not been trained or
certified to do. Prior to practice, review the duties and restrictions related to medical
assisting, which vary by state. Health care organizations may have stricter policies and
procedures that they enforce, but they must comply with state regulations at minimum.
Variables for the Scope of Practice
Variables that affect the scope of practice for medical assistants include the regulations
and policies issued by state medical boards. An MA with appropriate training may safely
provide supportive services that are simple, routine medical tasks under the supervision
of a licensed physician. In addition, the MA may only provide supportive services set
forth by the medical office’s organizational policies. These often include measuring
height and weight, measuring vital signs, and performing various diagnostic and

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laboratory testing. Organizational policies must adhere to state and government

guidelines to comply with current laws.
Titles
Over 50 years ago, medical providers began hiring assistants to support their medical
practice. They recognized the need for administrative support. Over time, this turned
into the MA role, combining administrative and clinical responsibilities. In 1956, a formal
medical assistant association was formed and recognized by 15 states. The profession
continued to evolve and was recognized by the U.S. Department of Education in 1978.
At that time, training was completed on the job by the provider and other office staff.
This eventually became time-consuming and expensive for providers, at which point
formalized training and certification programs arose. Many clinical offices look to hire
only those who have completed formal training and certification, ensuring they have the
necessary skill set to work in patient care. Offices also follow specific guidelines
requiring medical assistants to have current certification to input data regarding
government insurance reimbursements into electronic health records.
Additional Certifications
Medical assistants can further their careers and extend their scope of work through
continued education, leading to additional certifications, including the following.
Certified medical administrative assistant (CMAA)
Certified phlebotomy technician (CPT)
Certified EKG technician (CET)
Certified billing and coding specialist (CBCS)
Certified electronic health records specialist (CEHRS)

Provider and Allied Health Roles, Responsibilities, Scope of Practice, Titles,

and Credentials

Physician Information
When most people think of health care providers, they think of physicians, also known
as doctors. All practicing doctors must be licensed in the state where they practice. To
pursue a license, they must first complete eight years of school—four years of
undergraduate college, followed by four years of medical or osteopathic school. Upon
graduation, prospective physicians then move on to residency. Residency is a two- to
seven-year training period where they receive intensive on-the-job training with the
direct oversight of a licensed physician. Finally, physicians must pass parts I, II, and III of

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the U.S. Medical Licensing Examination. There are two primary types of physicians:
medical doctor (MD) and doctor of osteopathy (DO). Their scope of practice and
responsibilities are nearly the same, though their training and expertise have slight
variations.
Medical doctors are allopathic providers and the most widely recognized type of
doctor. They diagnose illnesses, provide treatments, perform procedures such as
surgical interventions, and write prescriptions.
Doctors of osteopathy complete requirements like those of MDs to graduate and
practice medicine. In addition to modern medicine and surgical procedures, DOs use
osteopathic manipulative therapy to treat patients.
In addition to physicians, there are two primary types of midlevel providers: physician
assistants and nurse practitioners.
Physician Assistant
Physician assistants (PA) must practice medicine under the direction and supervision of
a licensed MD or DO, but they can make clinical decisions. In order to be licensed as a
PA in the state of practice, individuals must first complete at least four years of college,
followed by two years of PA school. Most PAs will focus on a specific specialty, such as
cardiology or orthopedics.
Nurse Practitioner
Nurse practitioners (NP) provide basic patient care services, including diagnosing and
prescribing medications for common illnesses. Nurse practitioners require advanced
academic training beyond the registered nurse (RN) degree and have an extensive
amount of clinical experience. In most states, NPs must work under the supervision of a
physician, but in some states they can practice independently.
Nurses
Nurses are found in almost every health care setting.
A licensed practical nurse (LPN) must be licensed in their state. Typically, one year of
schooling through an accredited program, along with passing a state board
examination, is required to obtain an LPN license. LPNs are somewhat limited in their
scope of practice, as the role is designed to be assistive. They can measure vital signs,
administer some medications, and perform clinical care such as wound care. Often, the
role of an LPN is to observe patients, recording and reporting on status changes. While
they may work in many different settings, a primary use of LPNs recently is in long-term
care settings due to the increasing number of older adults in the general population.In
some states, and LPN may also be referred to as an LVN (licensed vocational nurse).

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A registered nurse (RN) must complete more schooling in the form of an associate
degree, diploma graduate, or baccalaureate degree. They, too, must pass a state board
examination to be licensed. Due to the more intensive training, RNs have a much
broader scope of practice than LPNs. RNs can work in clinical settings, public health
agencies, administrative capacities, and educational settings.
Allied Health Professionals
Medical laboratory technicians perform diagnostic testing on blood, bodily fluids, and
other specimens under the supervision of a medical technologist.
Medical receptionists check patients in and out, answer phones, schedule
appointments, and perform other administrative tasks.
Occupational therapists assist patients who have conditions that disable them
developmentally, emotionally, mentally, or physically.
Pharmacy technicians may perform routine medication dispensing functions that do not
require the expertise or judgment of a licensed pharmacist. Pharmacy technicians must
work under the direct supervision of a pharmacist.
Physical therapists assist patients in improving mobility, strength, and range of motion.
Radiology technicians use various imaging equipment to assist the provider in
diagnosing and treating certain diseases.

Licensing Versus Certification and Maintenance of Certification

Licensure vs. Certification

A medical school graduate must be licensed before beginning the practice of medicine.
Being licensed by the state to practice medicine allows them to diagnose conditions
and provide treatment. Licensing helps ensure that anyone providing medical care has
the adequate knowledge and skill set to do so safely. It is important to understand the
laws and regulations within each state to avoid violations of any kind.
Health Care Licensure
Licensure is regulated by state statutes through the medical practice acts. An MD, DO,
or Doctor of Chiropractic degree is issued upon graduation from a medical or
chiropractic institute.
Licensure for physicians is mandatory and controlled by a state board of medical
examiners. Licensure may be accomplished by examination, reciprocity, or
endorsement. Every state requires a written examination for MDs to practice. Some

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states grant the license to practice medicine by reciprocity, which automatically

recognizes that the requirements were met by another state. Graduates of medical
schools in the U.S. are licensed by the endorsement of the national board certification.
Licensure by endorsement is granted on a case-by-case basis based on examinations.
Graduates not licensed by endorsement must pass the state board exam.
As of 2022, no state requires medical assistants to be licensed. However, some states
dictate that to complete specific services such as x-rays, individuals must have a license
to perform that particular skill. For example, Florida does not require a medical assistant
to have a license to collect prescribed routine laboratory specimens. However, in
Washington, even nationally certified medical assistants must get licensing credentials
through the Washington State Department of Health to perform phlebotomy or EKGs.
Certification
In addition, the government may require certification for the medical assistant to enter
prescriptions into a computerized order-entry system. Advantages of certification
include increased initial job placement, higher wages, and career advancement
opportunities.
Maintaining a Certification
Once certification is obtained, it must be maintained to stay current. This ensures that
medical assistants have the most up-to-date information about the medical field and
provides validity to the overall profession. Each certification has different requirements
for recertification, so medical assistants should understand and follow the recertification
process of the organization sponsoring their certification.

Types of Health Care Organizations and Delivery Models

Inpatient and Outpatient

Inpatient care occurs while the patient is admitted to a hospital or facility. Ambulatory
care refers to any care received in an outpatient facility. This includes many types of
care settings.
Primary Care Clinics
Primary care clinics are outpatient care settings where patients are seen for routine type
visits, including wellness checks, prevention counseling, chronic conditions, medication
management, and minor acute needs. Primary care will be discussed in more detail later
in the chapter.
Specialty Care Clinics

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Specialty care clinics are outpatient facilities where patients who have complex or
severe diseases and conditions are seen for routine visits by doctors who specialize in a
specific disease or condition.
Home Health
Home health refers to specific types of care provided to those who cannot leave their
home easily. Physical, occupational, and speech therapy are common types of home
care. Skilled nursing is also common in the home health setting. It must be prescribed
and overseen by a provider, typically a primary care provider (PCP). Home health is not
used on an ongoing basis for a patient but is ordered for a set period based on an
acute event, usually hospitalization. Home health orders include goals for the patient,
such as managing their medications and ambulating safely. The service is complete
when the goals are reached. Medical assistants working for the ordering provider are
often responsible for submitting the order for home health, coordinating to ensure the
patient is enrolled and scheduled, and assisting with the administrative aspects of the
orders.
Mobile Health Units
Mobile health units bring health care to the communities that most need it and may
otherwise lack access to the services provided. Teams working in a mobile health unit
are equipped with means of transportation that allow for the setup and use of
specialized medical equipment. There are mobile health units in the U.S. While this
concept has been in use for services such as mobile stroke units, mobile urgent cares,
and mobile mammogram buses, the COVID-19 pandemic brought this type of care to
much of the country in the form of mobile testing and vaccination options.
Hospice
Hospice care is end-of-life care focused on comfort rather than curative efforts. Patients
can qualify for hospice care if they have a terminal illness at the end stage. It can be
delivered as outpatient or inpatient care. Typically, a patient will begin hospice
outpatient but can transition to inpatient care as they need a higher level of care near
the end of life.
Patient-Centered Medical Home
The patient-centered medical home (PCMH) is a care delivery model in which a PCP
coordinates treatment to ensure patients receive the required care when and where
they need it and in a way they can understand. This encompasses all aspects of care,
from prevention and wellness education to acute illness and chronic disease
management to end-of-life care. The PCMH is a team-based approach to health care in
which a provider leads an interprofessional team to work collaboratively and effectively
for their patients. Medical assistants are an integral piece of the PCMH team—assisting

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with direct patient care, care coordination, patient education, and administrative tasks
essential to the model.

Technology-Based Methods for Providing Health Care and Information

Telehealth and Virtual Visits

Telehealth is health care delivered virtually, most commonly via video call. The increase
in telehealth expanded to eliminate patients from coming in contact with
communicable diseases, provide convenience, and allow patients in rural areas to
obtain specialty care where it may not have been offered before. Telehealth can be an
excellent option for patients and providers to review many aspects of care, but it does
come with limitations.
Medical assistants may have multiple responsibilities when it comes to virtual visits.
Scheduling virtual visits may require more time because the MA must gather or confirm
the patient’s email address, ensure the link has been sent, and review instructions.
Some offices offer patients a test visit in which an administrator or MA will log into the
link to ensure the patient can access it when it is time for their appointment. Medical
assistants may also participate in the actual visit, just as they would with a standard
office visit. This can include gathering a history, verifying medication and pharmacy
information, setting an agenda, and following up with the patient on the next steps,
such as referral or diagnostic testing coordination.
Patient Portals
Patient portals are a common feature in electric health records. This feature allows
patients to log into a patient-facing aspect of the EHR to view their personal health
information, such as test results, visit notes, and patient education materials. Many
patient portals include an option to securely message the health care team about
concerns and plans of care. Some portals also allow patients to schedule appointments
directly without needing to call the office. The benefits of patient portals include
increased transparency about care, decreased wait times for patients to receive results,
and reduced demand on the office staff due to direct access limiting the need for
phone calls.
The MA may be responsible for uploading information to the portal, as well as assisting
the patient with enrolling and getting set up with an account. Medical assistants should
understand the portal’s functionality and the clinic’s policies and procedures around
appropriate use.

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Foundational Knowledge and Basic Science: Health Care Systems and Settings

Health Care Payment Models

Fee for Service

The U.S. health care system is largely based on the fee-for-service model in which
providers and medical facilities bill insurance and patients for the services provided.
Every examination, medical service, test, and procedure has an associated procedural
code and charge. These charges are managed through the provider’s medical billing
department and sent to the insurance (or directly to the patient) for payment. The
insurance then charges the patient a predetermined amount for which they are
responsible.
Value-Based Plans
The health care system is increasingly moving toward value-based plans or care. The
goals of value-based care are summarized in the Quadruple Aim.

• Improved patient outcomes

• Improved patient satisfaction

• Lower cost

• Health care professional well-being

Rather than costs being determined by each service, the cost is more holistic. This
model prioritizes prevention and early intervention over complex intervention to
prevent unnecessary downstream costs. Clinics and health care systems that adopt this
model are rewarded financially for keeping patients healthy rather than making money
based on visits, procedures, and interventions once the patient has become ill.
Other Health Care Models

MODEL DESCRIPTION

Managed care An umbrella term for plans that provide health care in return for preset
scheduled payments and coordinated care through a defined network
of providers and hospitals.

Capitation (partial or Patients are assigned a per-member, per-month payment based on

full) age, race, sex, lifestyle, medical history, and benefit design. Payment
rates are tied to expected usage regardless of how often the patient
visits. Like bundled payment models, providers are incentivized to help
patients avoid high-cost procedures and tests to maximize their
compensation. Under partial- or blended-capitation models, only
specific types or categories of services are paid based on capitation.

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MODEL DESCRIPTION

Health maintenance This plan contracts with a medical center or group of providers to
organization (HMO) provide preventive and acute care for the insured person. HMOs
generally require referrals to specialists, as well as precertification and
preauthorization for hospital admissions, outpatient procedures, and
treatments.

Preferred provider These plans have more flexibility than HMO plans. An insured person
organization (PPO) does not need a PCP and can go directly to a specialist without
referrals. Although patients can see providers in or out of their
network, an in-network provider usually costs less.

Point-of-service (POS) POS plans allow a great deal of flexibility for patients. They can self-
plan refer to specialists and do not need an assigned PCP. Like PPO, the
cost depends on whether the providers they see are within the plan’s
panel.

General vs. Specialty Health Care and Services

General Health Care Services

General practitioners (GPs) are medical doctors who treat acute and chronic illnesses
and provide patients with preventive care and health education. A GP may take a
holistic approach to general practice that considers the biological, psychological, and
social aspects relevant to the care of each patient’s illness.
Family practitioners offer care to the whole family, from newborns to older adults. They
are familiar with a range of disorders and diseases. However, preventive care is their
primary concern.
Internists provide comprehensive care for adults, often diagnosing and treating chronic,
long-term conditions. They also offer treatment for common illnesses and preventive
care. Internists must have a broad understanding of the body and its ailments to
diagnose conditions and provide treatment. Internists may focus on pediatric or adult
medicine rather than provide care across the lifespan.
Specialty Health Care Services
Specialist care is used when a disease or diagnosis escalates beyond the area of
expertise of a PCP. Specialists are providers focused on diagnosing and treating
diseases and disorders of specific body systems.
Specialist Care

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SPECIALIST FOCUS

Allergist Evaluates disorders and diseases of the immune system, including adverse
reactions to medications and food, anaphylaxis, problems related to
autoimmune disease, and asthma

Anesthesiologist Manages pain or administers sedation medications during surgical procedures

Cardiologist Diagnoses and treats diseases or conditions of the heart and blood vessels

Dermatologist Diagnoses and treats skin conditions

Endocrinologist Diagnoses and treats hormonal and glandular conditions; often works with
patients who have diabetes

Gastroenterologist Manages diseases of the GI tract (stomach, intestines, esophagus, liver,

pancreas, colon, and rectum)

Gynecologist Diagnoses and treats internal reproductive system and fertility disorders

Hematologist Diagnoses and treats blood and blood-producing organs, patients who have
anemia, leukemia, and lymphoma

Hepatologists Studies and treats diseases related to the liver, biliary tree, gallbladder, and
pancreas

Neonatologist Provides care of newborns, specifically those who are ill or premature

Nephrologist Manages diseases and disorders of the kidney and its associated structures

Obstetrician Provides care of patients during and after pregnancy

Oncologist Treats and provides care for patients who have cancer

Ophthalmologist Diagnoses and treats diseases and conditions of the eye

Orthopedist Treats injuries and diseases of the bones, joints, muscles, tendons, and
ligaments

Neurologist Treats diseases and disorders of the brain and nervous system

Otolaryngologist Treats diseases and conditions of the ear, nose, and throat

Pediatrician Manages newborn to adolescent health

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SPECIALIST FOCUS

Psychiatrist Diagnoses and treats mental disorders and conditions

Radiologist Uses and interprets imaging to detect abnormalities in the body

Urologist Manages disorders of the urinary tract

Ancillary Services and Complementary Therapies

Ancillary Services
Providing ancillary services in the provider’s office adds convenience for patients and
increases revenue for the organization. Ancillary services meet a specific medical need
for a particular population.
Urgent care provides an alternative to the emergency department. They cost less, have
a shorter wait time, and are often conveniently located. Most have flexible hours and
offer walk-in appointments. They are appropriate to use for non-life-threatening acute
injuries and illnesses.
Laboratory services perform diagnostic testing on blood, body fluids, and other
specimens to conclude a diagnosis for the provider.
Diagnostic imaging machines such as x-ray equipment, ultrasound machines, magnetic
resonance imaging (MRI), and computerized tomography (CT) take images of body
parts to further diagnose a condition.
Occupational therapy assists patients who have conditions that disable them
developmentally, emotionally, mentally, or physically. Occupational therapy helps the
patient compensate for the loss of functions and rebuild to a functional level.
Physical therapy assists patients in regaining mobility and improving strength and range
of motion, often impaired by an accident, injury, or disease.
Complementary Therapies
Acupuncture involves pricking the skin or tissues with needles to relieve pain and treat
various physical, mental, and emotional conditions.
Chiropractic medicine diagnoses and treats pain and overall body function through
spinal manipulation and alignment.
Energy therapy is the calm method of clearing cellular memory through the human
energy field, promoting health, balance, and relaxation. It centers on the connection

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between life’s physical, emotional, and mental states found in various holistic healing
techniques.
Dietary supplements contain one or more dietary ingredients, including vitamins,
minerals, herbs, or other botanicals. A plant or part of a plant (flowers, leaves, bark, fruit,
seeds, stems, roots, amino acids) is used for its flavor, scent, or potential therapeutic
properties.

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Psychology
Developmental stages
One of the most generally accepted developmental theories is the work of Erik Erikson.
His eight stages of development offer a guideline for identifying the psychosocial
challenges patients face at different periods in their lives and the tasks they must master
before successfully transitioning to the next stage of development. Erikson believed
that society and culture affect how the personality of an individual develops and that
successful completion of each stage supports the healthy development of the person’s
ego.
Trust vs. Mistrust
This is the psychosocial crisis for infants. Trust is the successful outcome of this stage.
Mistrust is the unsuccessful outcome.
The developmental tasks for infants are to form an attachment with and develop trust in
their primary caregiver and then generalize those bonds to others. They also begin to
trust their own body as they learn gross and then fine motor skills. Achieving the tasks of
this stage results in self-confidence and optimism that caregivers will meet the infant’s
basic needs. Nonachievement leads to suspiciousness and struggles with interpersonal
relationships.
Autonomy vs. Shame and Doubt
This is the psychosocial crisis for toddlers. Autonomy is the successful outcome of this
stage. Shame and doubt are the unsuccessful outcome. During this stage, toddlers
begin to develop a sense of independence, autonomy, and self-control. They also
acquire language skills. Parents should be firm but tolerant with toddlers. Achieving the
tasks of this stage results in self-control and voluntary delaying of gratification.
Nonachievement leads to anger with self, a lack of self-confidence, and no sense of
pride in the ability to perform tasks
Initiative vs. Guilt
This is the psychosocial crisis for preschoolers. Initiative is the successful outcome of this
stage. Guilt is the unsuccessful outcome. During this stage, children look for new
experiences but will hesitate when adults reprimand them or restrict them from trying
new things.

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Preschoolers have an active imagination and are curious about everything around them.
Eventually they will start feeling guilt for some of their actions, which is part of the
natural development of moral judgment.
Achieving the tasks of this stage results in assertiveness, dependability, creativity, and
personal achievement. Nonachievement leads to feelings of inadequacy, defeat, and
guilt and the belief that they deserve punishment.
Industry vs. Inferiority
This is the psychosocial crisis for school-age children. Industry is the successful outcome
of this stage. Inferiority is the unsuccessful outcome. During this stage, children need to
receive recognition for accomplishments to provide reinforcement and build self-
confidence. If the achievements are met with a negative response, inferiority can be
established. Children require acknowledgment of their successes. Achieving the tasks of
this stage results in feelings of competence, self-satisfaction, and trustworthiness in
addition to increased participation in activities and taking on more responsibilities at
school, home, and the community. Nonachievement leads to feelings of inadequacy
and the inability to compromise or cooperate with others.
Identity vs. Role Confusion
This is the psychosocial crisis for adolescents. Identity is the successful outcome of this
stage. Role confusion is the unsuccessful outcome. During this stage, adolescents try to
figure out where they fit in and what direction their life should take. If role confusion
sets in, adolescents become followers, which can lead to poor decision-making.
Achieving the tasks of this stage results in emotional stability, ability to form committed
relationships, and sound decision-making. Nonachievement leads to a lack of personal
goals and values, rebelliousness, self-consciousness, and a lack of self-confidence.
Intimacy vs. Isolation
This is the psychosocial crisis for young adults. Intimacy is the successful outcome of this
stage. Isolation is the unsuccessful outcome. During this stage, young adults begin to
think about partnership, marriage, family, and career. Lack of fulfillment in this key area
of life can lead to isolation and withdrawal. Achieving the tasks of this stage results in
the ability for mutual self-respect and love, intimacy, and commitment to others and to
a career. Nonachievement leads to social isolation and withdrawal; multiple job
changes or lack of productivity and fulfillment in one job; and an inability to form long-
term, intimate, or close relationships.
Generativity vs. Stagnation
This is the psychosocial crisis for middle adults. Generativity is the successful outcome
of this stage. Stagnation is the unsuccessful outcome. During this stage, adults continue
raising children, and some become grandparents. They want to help mold future

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generations, so they often involve themselves in teaching, coaching, writing, and social
activism. Achieving the tasks of this stage results in professional and personal
achievements and active participation in serving the community and society.
Nonachievement occurs when development ceases, which leads to self-preoccupation
without the capacity to give and share with others.
Ego Integrity vs. Despair
This is the psychosocial crisis for older adults. Ego integrity is the successful outcome of
this stage. Despair is the unsuccessful outcome. During this stage, most adults retire;
their children, if they have any, no longer live at home. Many will volunteer to retain a
feeling of usefulness. Their bodies experience age-related changes, and health
becomes a major concern, especially as friends and loved ones die. Achieving the tasks
of this stage results in wisdom, self-acceptance, and a sense of self-worth as life draws
to a close. Nonachievement leads to dissatisfaction with one’s life, feelings of
worthlessness, helplessness to change, depression, anger, and the inability to accept
that death will occur.

Common Mental Health Conditions

Mental health is as important as physical health when it comes to overall wellness.
Mental health refers to a person’s cognitive abilities, behaviors, and emotions. Mental
health conditions and illnesses can be caused by biological issues (such as genetics),
environmental issues (such as learned behaviors, poor coping mechanisms, traumatic
experiences), or a combination of both. There are over 300 recognized mental illnesses,
many with overlapping symptoms. Understanding how to interact empathically and
effectively with a patient suffering from a mental illness is key for medical assistants (and
all health care professionals). This involves being patient and professional in all
interactions, building trust with the patient, and working together with the patient and
provider to understand appropriate and helpful language and actions to communicate
with each individual patient effectively. Treatment includes medications and behavior
therapies.

Common Mental Health Conditions

CONDITION DESCRIPTION SIGNS AND SYMPTOMS TREATMENT

Depression Mood disorder that Extreme sadness, fatigue, Typically managed

can be caused by a lethargy, hopelessness, pain, best with a
chemical imbalance digestive issues, extreme lack combination of
in the brain of motivation (even with therapy, healthy
activities and hobbies that lifestyle, and
previously were enjoyable), medication
thoughts of suicide

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CONDITION DESCRIPTION SIGNS AND SYMPTOMS TREATMENT

Attention- Chronic condition Inattention in which the Medications and

deficit/hyperact that typically begins individual struggles to behavior therapies
ivity disorder in childhood but can regulate attention and focus,
(ADHD) impact individuals making it difficult to follow
throughout their life directions and stay organized
Hyperactivity and impulsivity
can present as constant
fidgeting, excessive talking,
and struggling with quiet
activities.
More commonly diagnosed in
boys

Anxiety Disorders that lead Uncontrolled levels of stress, Therapy, healthy

to extreme feelings fast heart rate, sweating, and lifestyle, and
of worry and fear, being consumed by worry medication
to the point that the
person’s ability to
function and
respond to typical
situations is
inhibited

Post-traumatic A condition Intrusive memories (such as Psychotherapy,

stress disorder resulting from a flashbacks to the event), exposure therapy, and
(PTSD) traumatic or negative changes (negative medication
terrifying event thoughts and hopelessness),
Not everyone who changes in reactions (new
experiences a and potentially aggressive
traumatic event will behaviors), trouble with
develop PTSD. concentration and sleep, self-
destructive behaviors, and
War veterans;
avoidance (avoiding places,
people who have
people, or experiences
experienced
associated with the negative
physical, emotional,
event; avoiding loved ones;
or sexual abuse;
avoidance of discussing the
people who have
event)
lived through an
attack or natural
disaster; and those
who have lost a
loved one might
experience PTSD.

Environmental and Socioeconomic Stressors

A stressor is anything that causes anxiety or stress. Many things in the environment
cause stress, as do psychological factors (grief, depression, loss, guilt). Even things that

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are positive (taking a vacation, having an intimate experience, graduating from college)
can be stressors. Coming to a health care facility can create a great deal of stress for a
patient. This can be reflected by an increase in blood pressure in the office that is not
reflected in the patient’s readings from home, commonly called white-coat syndrome.
This is an objective indication of the patient’s anxiety.
Environmental Stressors
Environmental stressors, or physical stressors, include situations that cause enough
stress to become obstacles to achieving goals or having positive experiences. Things in
the environment (air pollution, ultraviolet rays from excessive sun exposure,
overcrowding, language and cultural barriers, discrimination) cause the body physical
stress.
Events in the environment (death of a loved one, theft, vandalism, motor-vehicle
crashes, physical assault, job, school problems) can also cause stress. Major disasters
(fires, floods, tornadoes, earthquakes, hurricanes, war) can result in PTSD, which causes
anxiety, insomnia, anger, loss of interest in daily activities, and flashbacks to the
traumatizing event.
Even though a stressor might originate from the environment, the mind interprets the
severity of the situation and helps the person cope with it in a positive way. From there,
people deal with the stressor based on their perception, experience, and resources they
have available to them. When they cannot cope with the situation or do not have
adequate support systems, they can develop any number of negative outcomes.
Socioeconomic Stressors
Many people undergo a great deal of stress over financial situations. Life is expensive;
sometimes it seems like an endless cycle of working and struggling to meet expenses
and pay debts. Just when it seems that getting ahead financially is within reach, a
sudden unexpected expense (medical bills, vehicle repair) or a job loss eliminates the
possibility of economic balance, and the expenses and debt may pile up. Even people
who have not had a great deal of socioeconomic stress in their lives can suddenly find
themselves in a stressful situation due to retirement, changes in the economy that lead
to a loss of investments, identity theft, lack of job security, involuntary job loss (getting
fired), or the loss of a home or vehicle. Medical assistants encounter patients who have
minimal health insurance and find the out-of-pocket costs of many diagnostic
procedures, treatments, and medications beyond what they can afford.

Communication and Accommodations

A general understanding of the principles of therapeutic communication is helpful when
working with all patients. For example, medical assistants can encourage patients to
express their feelings by reflecting patients’ statements back to them in a way that

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promotes further communication. It is also helpful to make observations and offer

recognition of positive changes. These techniques promote positive communication.
Patients can also have specific types of problems that require special consideration and
techniques. The medical assistant helps build and nurture the relationship with all
health care staff.
Physical Disability
Medical offices and facilities are legally required, according to the Americans with
Disabilities Act, to have appropriate access for patients who use wheelchairs or other
assistive devices. These include marked parking spaces, ramps, and accessible
bathrooms with large stalls and handrails. Medical assistants can ensure these patients
are comfortable and able to function well in their surroundings by organizing common
areas. The patients will feel more at ease, and it will be easier to build therapeutic
relationships with them. They will see the office staff has anticipated their needs and
facilitated their navigation throughout the office.
Many patients who have disabilities experience instances of people making tactless
remarks or asking inappropriate questions. Only ask questions regarding their disability
as part of a medical evaluation or history gathering. Instead of asking “How did that
happen to you?” ask “What can I do to assist during your visit?” Being over-solicitous
can come across as insincere. Be prepared to provide any necessary accommodations,
but do not make assumptions. Ask the patient what they require and respect their
answer.
Developmental Delay
The first step when working with patients who have mental or emotional disabilities is to
determine how they communicate and what level of communication they understand.
Family members and caregivers can assist with this, but do not assume the patient is
incapable of communicating. Always address the patient first. Remain calm, avoid
showing impatience, and speak at a consistent volume. Any time you cannot
understand something the patient says, ask for clarification. Advocate for patients and
always treat them with respect and empathy. Provide accommodations to meet
patients’ needs and ask how to assist during their visit.
Illness and Disease
Individuals who have chronic or terminal illness are under an extreme amount of stress.
Casual, routine opening lines like an excessively cheerful “How are you doing today?”
can provoke defensive responses like, “How do you think I’m doing? I’m dying.” Even if
the patient doesn’t say that, they might think it. Instead, welcome these patients warmly
and respect their dignity. Treat them with kindness and care at all times.

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Offer support and empathy, and allow the patient to set the tone of the conversation.
Never say you know how the patient feels. All feelings are unique to the individual, so to
express this belittles the person and shows a lack of respect for their individuality. Listen
carefully to the patient, maintain eye contact, and always ask how to help. Prior to
beginning medical data collection, use a broad opening like, “What would you like to
talk about today?” How the patient answers will help set the tone for the remainder of
the interaction.
Make sure the patient has all the services they need, such as hospice referrals, meal-
delivery services, and home health assistance. Support groups and community services
can also help; these services can provide social experiences and an outlet for dying
patients and their families.

Defense Mechanisms
Defense mechanisms are coping strategies people use to protect themselves from
negative emotions such as guilt, anxiety, fear, and shame. Individuals are generally
unaware that they are using these responses to stress. Developing the ability to
recognize these defense mechanisms and the emotions behind them can help medical
assistants tremendously in understanding patients and helping to meet their needs.

Common Defense Mechanisms

DEFENSE
MECHANISM MEANING EXAMPLE

Apathy Indifference; lack of interest, “I don’t care what she puts in my

feeling, concern, or emotion evaluation, it won’t change anything.”

Compensation Balancing a failure or inadequacy “I ate a lot of candy yesterday, but I

with an accomplishment also ate a big green salad.”

Conversion Transformation of an anxiety into a “I get a severe headache every time I

physical symptom that has no see my ex with his new wife.”
cause

Denial Avoidance of unpleasant or “I am healthy and fit. There is no way I

anxiety-provoking situations or have cancer, so I don’t need all those
ideas by rejecting them or ignoring tests.”
their existence

Displacement Redirection of emotions away from “I had enough trouble handling that
the original subject or object onto last patient. I don’t need to deal with
another, less-threatening subject or this malfunctioning copier right now.”
object

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DEFENSE
MECHANISM MEANING EXAMPLE

Dissociation Disconnection of emotional “I’m always getting into fights with my

importance from ideas or events neighbors, which is odd because I
and compartmentalizing those teach an online course in conflict
emotions in different parts of resolution.”
awareness

Identification Attribution of characteristics of “I could pass that certification test

someone else to oneself or the just like she did, and I haven’t even
imitation of another studied the material.”

Intellectualization Analysis of a situation with facts “He didn’t break up with me because
and not emotions he didn’t love me. He just had too
much on his plate at work at the
time.”

Introjection Adoption of the thoughts or “My dad says I should stand up for
feelings of others myself, so I am going to be more
assertive.”

Physical Keeping away from any person, “I can’t go to that hospital because
avoidance place, or object that evokes that’s where my father died.”
memories of something unpleasant

Projection Transference of a person’s “She leaves more charts incomplete

unpleasant ideas and emotions than I do, so why am I getting this
onto someone or something else warning?”

Rationalization Explanation that makes something “My partner drinks every night to
negative or unacceptable seem make himself less anxious about
justifiable or acceptable work.”

Reaction Belief in and expression of the “I really hate being in the military, but
formation opposite of one’s true feelings I always sign some people up at
recruitment events.”

Regression Reversion to an earlier, more “I can’t do all that paperwork, and you
childlike, developmental behavior can’t make me.”

Repression Elimination of unpleasant emotions, “They tell me I was hurt in that

desires, or problems from the robbery, but I can’t remember
conscious mind anything about it.”

Sarcasm Use of words that have the “You have a nice office if you like
opposite meaning, especially to be working in caves.”
funny, insulting, or irritating

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DEFENSE
MECHANISM MEANING EXAMPLE

Sublimation Rechanneling unacceptable urges “When I was a kid, I used to like to

or drives into something pull wings and legs off insects I’d
constructive or acceptable catch. Now I am a biology teacher.”

Suppression Voluntary blocking of an “The doctor said I need more tests,

unpleasant experience from one’s but I’m going to take my vacation
awareness first.”

Undoing Cancelling out an unacceptable “I had a big fight with my wife last
behavior with a symbolic gesture night, but I’m going to buy her some
flowers on my way home today.”

Verbal aggression Verbal attack on a person without “Why would you ask me that when
addressing the original intent of you can’t even control your children?”
the conversation

End of Life and Stages of Grief

As people age and their physiologic abilities and reserves dwindle, they tend to seek
more health care services.
After age 60, many people start to think about their own mortality. They realize that so
much of their life is behind them, and they begin to wonder how many “good years”
they have left. For many, their adult children live long distances away and have families
and careers of their own. It gradually becomes more difficult for older adults to continue
to work, maintain their home, and—depending on what health conditions they have—
participate in activities they enjoy as well as activities of daily living. They worry that
minor issues, like forgetting to buy an item they need at the grocery store or misplacing
their keys, mean they are developing dementia. Those whose capacity for independent
living has diminished can become victims of elder abuse, which can involve neglect or
physical abuse, often perpetrated by caregivers or family members who are
overwhelmed with the burden of caring for the aging individual.
Many older adults deal with constant grief as friends, neighbors, and family members
die. They may also grieve for themselves—for their younger, healthier days and for the
abilities they are losing or have lost. They hear many clichés, such as “Just take
one day at a time,” “Don’t worry about what hasn’t happened yet,” and “You’re only as
old as you feel.” However, these platitudes offer little comfort to older adults grappling
with the grim realities of aging.
All patients need support when they encounter the health care system, and older adults
are a unique population because they face so many challenges toward the end of life.

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The physical challenges are real, and the feelings of grief can be overwhelming. This
leads to a major health concern for older adults: depression.
End-of-Life Struggles
Many older patients have chronic or terminal illnesses that influence them to prepare
for the end of life. Patients should arrange for end-of-life care, funeral, burial, and
cremation services. If the person has a dependent, such as a partner, the dying person
will need to make financial or caregiving arrangements. The person also needs to have
advance directives in place, as well as a will and a durable power of attorney for health
care document available. These preparations bring the reality of the end of life into
sharp focus and generally put the patient and loved ones into a state of anticipatory
grief. This means that they are feeling the emotions and reactions that grief causes
before the loss occurs.
Stages of Grief – Kübler-Ross
Just like with developmental stages, several theorists have defined the various stages of
grief. The most well-known theory is the five stages of grief Elisabeth Kübler-Ross
defined as a result of her extensive experience in working with dying patients.
Awareness of these stages can help medical assistants understand what grieving
patients are experiencing, whether the loss is the death of a loved one, body part or
function, finances, home, or any number of other losses that have a strong and lasting
effect on the person.
Not everyone grieves in the same way. While one person might navigate through the
stages of grief one by one and in sequence, others can be in more than one stage
simultaneously. Some might skip one or more stages. The duration of the process is
also highly variable. There is no right way to grieve. The stages of grief that Kübler-Ross
defined are as follows.
Denial
During this stage, the grieving person cannot or will not believe that the loss is
happening or has happened. They might deny the existence of the illness and refuse to
discuss therapeutic interventions. Thought processes reflect the idea of “No, not me.”
Support the patient without reinforcing the denial. It might help to give the patient
written information about the disease and treatment options with the approval of the
provider.
Anger
During this stage, the grieving person might aim feelings of hostility at others, including
health care staff (because they cannot fix or cure the disease). Thought processes reflect
the idea of “Why me?” Do not take the patient’s anger personally. Instead, help them
understand that becoming angry is an expected response to grief.

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Bargaining
During this stage, the grieving person attempts to avoid the loss by making a deal, such
as wanting to live long enough to attend a particular family occasion. The patient might
also be searching for alternative solutions. They are still hoping for their previous life, or
life itself, or at least a postponement of death. Thought processes reflect the idea of
“Yes, me, but...” Listen with attention and encourage the patient to continue
expressing their feelings.
Depression
During this stage, the reality of the situation takes hold, and the grieving person feels
sad, lonely, and helpless. For example, they might have feelings of regret and self-
blame for not taking better care of themselves. They might talk openly about it or might
withdraw and say nothing about it. Thought processes reflect the idea of “Yes, it’s me.”
Sit with the patient and do not put any pressure on them to share their feelings. Convey
support and understanding. Referrals to a support group or for counseling can be
helpful.
Acceptance
During this stage, the grieving person comes to terms with the loss and starts making
plans for moving on with life despite the loss or impending loss. They are willing to try
to make the best of it and formulate new goals and enjoy new relationships. If death is
imminent, they will start making funeral and burial arrangements and might reach out to
friends and family who have not been a part of their recent years of life. There might still
be some depression, but there might also be humor and friendly interaction. Thought
processes reflect the idea of “Yes, me, and I’m ready.” Offer encouragement, support,
and additional education to the patient and their family and friends during this time.

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Basic Pharmacology
Drug Classifications, Indications, and Commonly Prescribed Medications
The classification of medications is complex. Primarily, a medication’s therapeutic action
dictates the classification, but sometimes it is done by chemical formulations, body
systems they act on, or symptoms the medication relieves. Some medications fall into
more than one category. Gabapentin and pregabalin are good examples. Both
medications are anticonvulsants; they treat seizures. However, they are also analgesics
because they help relieve neuropathic (nerve) pain. Another example is
hydrochlorothiazide, a diuretic—it helps eliminate excess fluid from the body. However,
doing so can help lower blood pressure; thus, it is also an antihypertensive medication.
Here are some of the most common classifications of medications medical assistants
are likely to encounter.

Medication Classifications: Indications and Examples

MEDICATION
CLASSIFICATION INDICATION EXAMPLES

analgesics relieve pain acetaminophen, hydrocodone,

codeine

antacids/anti-ulcer Gastroesophageal Reflux esomeprazole, calcium carbonate,

Disease (GERD) famotidine

antibiotics bacterial infections amoxicillin, ciprofloxacin,

sulfamethoxazole

anticholinergics smooth muscle spasms ipratropium, dicyclomine,

hyoscyamine

anticoagulants delay blood clotting warfarin, apixaban, heparin

anticonvulsants prevent or control seizures clonazepam, phenytoin, gabapentin

antidepressants relieve depression doxepin, fluoxetine, duloxetine,

selegiline

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MEDICATION
CLASSIFICATION INDICATION EXAMPLES

antidiarrheals reduce diarrhea bismuth subsalicylate, loperamide,

dipehnoxylate/atropine

antiemetics reduce nausea, vomiting metoclopramide, ondansetron

antifungals fungal infections fluconazole, nystatin, miconazole

antihistamines relieve allergies diphenhydramine, cetirizine,

loratadine

antihypertensives lower blood pressure metoprolol, lisinopril, valsartan,

clonidine

anti-inflammatories reduce inflammation ibuprofen, celecoxib, naproxen

antilipemics lower cholesterol atorvastatin, fenofibrate,

cholestyramine

antimigraine agents relieve migraine headaches topiramate, sumatriptan, rizatriptan,

zolmitriptan

anti-osteoporosis agents improve bone density alendronate, raloxifene, calcitonin

antipsychotics psychosis quetiapine, haloperidol, risperidone

antipyretics reduce fever acetaminophen, ibuprofen, aspirin

skeletal/muscle reduce or prevent muscle cyclobenzaprine, methocarbamol,

relaxants spasms carisoprodol

antitussives/expectorant control cough, promote the dextromethorphan, codeine,

s elimination of mucus guaifenesin

antivirals viral infections acyclovir, interferon, oseltamivir

anxiolytics (anti-anxiety) reduce anxiety clonazepam, diazepam, lorazepam

bronchodilators relax airway muscles albuterol, isoproterenol,

theophylline

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MEDICATION
CLASSIFICATION INDICATION EXAMPLES

central nervous system reduce hyperactivity methylphenidate,

stimulants dextroamphetamine,
lisdexamfetamine

contraceptives prevent pregnancy medroxyprogesterone acetate,

ethinyl estradiol, drospirenone

decongestants relieve nasal congestion pseudoephedrine, phenylephrine,

oxymetazoline

diuretics eliminate excess fluid furosemide, hydrochlorothiazide,

bumetanide

hormone replacements stabilize hormone deficiencies levothyroxine, insulin,

desmopressin, estrogen

laxatives, stool softeners promote bowel movements magnesium hydroxide, bisacodyl,

docusate sodium

oral hypoglycemics reduce blood glucose metformin, glyburide, pioglitazone

sedative-hypnotics induce sleep/relaxation zolpidem, temazepam, eszopiclone

Drug Classifications and Schedules of Controlled Substances

The federal Controlled Substances Act (CSA) created five schedules for controlled
substances according to their potential for abuse and addiction. Only controlled
substances are classified as scheduled. Medical assistants must understand these
schedules, including the effect on how medications are prescribed and managed, to
ensure they follow appropriate protocols and support the patient. Patients who need
these medications may feel frustrated or shamed by the regulations in place if they
need help understanding the reasons or believe the restrictions are personal. When a
new controlled substance is prescribed, the MA can improve the patient experience by
setting expectations and normalizing the experience.
Schedule I includes substances with a high potential for abuse and currently no
approved medical use in the U.S. They are illegal, and providers may not prescribe
them. These include heroin, mescaline, and lysergic acid diethylamide (LSD). Schedule I
still includes cannabis (marijuana) even though it is legal for medical use with a
prescription in many states. States can add substances to a schedule as a matter of
state law, even if not included in federal scheduling. In the case of marijuana, the

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federal government does not federally prosecute those who use cannabis in states that
allow it.
Schedule II includes substances that have a high potential for abuse, are considered
dangerous, and can lead to psychological and physical dependence. Unlike schedule I
drugs, schedule II drugs are approved for medical use. Schedule II drugs include
morphine, methadone, oxycodone, hydromorphone, hydrocodone, fentanyl, and
amphetamine. Schedule II prescriptions must be signed by hand, except as rules allow
regarding distribution of electronic or printed prescriptions. Prescribers may
electronically transmit prescriptions directly to the pharmacy in states where the
prescription meets the requirement of state and federal regulations. Schedule II
substances must be stored in a safe or steel cabinet of substantial construction. If the
safe or cabinet is less than 750 pounds, it must be mounted or secured to something of
substantial construction. The device should have an inner and outer door with locks for
each door requiring different keys.
Schedule III includes substances with moderate to low potential for physical and
psychological dependence. These include ketamine, anabolic steroids, acetaminophen
with codeine, and buprenorphine.
Schedule IV includes substances that have a low potential for abuse and dependence.
These include tramadol and benzodiazepines including diazepam, alprazolam,
chlordiazepoxide, and clonazepam.
Schedule V includes substances that contain limited quantities of some narcotics,
usually for antidiarrheal, antitussive, and analgesic purposes. These include
diphenoxylate with atropine, guaifenesin with codeine, and pregabalin.
Schedule III, IV, and V controlled substances may not be filled or refilled more than 6
months after the date on which the prescription was issued and may not be refilled
more than five times in 6 months.
For a current alphabetical list of all controlled substances and their CSA schedule
number, go to the resources section of the Office of Diversion Control website.

Side Effects, Adverse Effects, Indications, and Contraindications

Medications can have good and bad effects.
Therapeutic effects are the good effects—the ones for which providers prescribe them.
Side effects are undesirable unintended actions on the body, such as nausea or dry
mouth, and can limit the usefulness of the medication.
Adverse effects are unintended, harmful actions of the medication, such as an allergic
reaction, and prevent further use of the medication.
Indications are the problems for which the provider prescribes a particular medication.

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Contraindications are symptoms or conditions that make a specific treatment or

medication inadvisable or even dangerous.
Precautions are problems that pose a lesser risk but require close observation and
monitoring during medication therapy.
Side Effects and Adverse Effects
Many people use side effects and adverse effects interchangeably, but there is a
difference. Side effects develop predictably and are nearly unavoidable but not
necessarily harmful. For example, a patient who takes diphenhydramine, an
antihistamine, to relieve an itchy rash at bedtime sleeps better that night. Why?
Because a side effect of diphenhydramine is sedation and sleepiness. So, advise caution
when taking this medication prior to driving or operating machinery.
The expected therapeutic effect of lisinopril is a sustained reduction in blood pressure.
Lisinopril can also cause many undesirable effects—some of them life-threatening. It is
critical to review with a patient who is beginning medication therapy what side effects
are the most common and which are serious enough to report to the provider
immediately. With lisinopril, the patient might develop nausea, dizziness, or nasal
congestion. These are common side effects and are likely to subside with time.
However, immediate medical care is imperative if the patient develops swelling of the
lips, face, and tongue. These could potentially indicate a fatal reaction to the
medication.
With lisinopril, facial swelling is a rare effect due to the accumulation of a substance in
the body that mimics anaphylaxis, a serious allergic reaction. Most medications have the
potential to cause an allergic reaction.
Mild allergic reactions usually manifest as itchy rashes.
Serious allergic reactions involve spasms of the airways, swelling of the face and throat,
and a serious decrease in blood pressure.
The patient’s allergy history can explain the possibility of an allergic reaction. For
example, if a patient has had a previous serious allergic reaction to eggs, they could
have a serious allergic reaction to the flu vaccine because eggs have been used in some
flu vaccines. For a serious or anaphylactic reaction, the patient needs epinephrine and
medical attention. Medication allergies should be discussed, reviewed, and updated at
every visit. Confirm allergies any time a prescription is written and prior to medication
administration.

Indications and Contraindications

The indication for a medication is the symptoms or reason a medication is prescribed,
while contraindications are symptoms or conditions that make a particular treatment or
medication inadvisable or even dangerous. The most common contraindication is

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hypersensitivity, a previous allergic reaction, to that medication. Other frequent

contraindications include damage to or malfunction of a body system. For example,
cirrhosis of the liver is a contraindication for taking acarbose, and hepatitis is a
contraindication for taking duloxetine. Many other medications are toxic to the liver and
require extreme caution with patients who have liver disease. These include
acetaminophen, phenytoin, fluconazole, bupropion, penicillin, erythromycin, rifampin,
ritonavir, lisinopril, and losartan.
Another important consideration is how a medication interacts with food or other
medications. It is easy to confuse contraindications with interactions. For example,
medications that are in the classification of a specific type of antidepressant,
monoamine oxidase inhibitors (MAOIs), interact dangerously with foods that contain
tyramine (avocados, smoked meats, wine, most cheeses). MAOIs also interact adversely
with other antidepressants, such as tricyclic antidepressants. Both interactions result in a
hypertensive crisis. Examples of MAOIs are phenelzine, isocarboxazid, and
tranylcypromine.
Grapefruit juice interacts with many medications, interfering with their metabolism,
raising the levels of the medications, and producing toxicity. These medications include
dextromethorphan, simvastatin, and sildenafil. Additionally, some herbal supplements
interact with prescription medications. St. John’s wort, an herbal supplement for mood
and sleep disorders, reduces the effectiveness of warfarin and oral contraceptives.
Even more common are medications that interact with other medications. For example,
if patients take propranolol with albuterol, both medications lose effectiveness. Aspirin
and warfarin have anticoagulant effects, so taking both puts patients at risk of
hemorrhage, or major bleeding. Many antibiotics—including ampicillin,
sulfamethoxazole-trimethoprim, minocycline, and metronidazole—reduce the
effectiveness of oral contraceptives.
For examples of medication indications, refer to the table of common medication
classifications. Their actions apply to the common reasons for use, including pain,
infection, muscle spasms, migraine headaches, anxiety, depression, or insomnia.
Common potential adverse effects include gastrointestinal problems (nausea, vomiting,
diarrhea, constipation). Some patients take medications with food to minimize these
effects. Furthermore, if stomach irritation is a problem, taking a formulation with an
enteric coating can help minimize the negative effects on the stomach. Also common
are central nervous system effects (dizziness, headache, sedation, insomnia). Many
medications cause changes in heart rate, blood pressure, vision, and hearing.

Metric and Standard Measurements, Dosage Calculations, and

Mathematical Conversions and Formulas
Understanding systems of measurement and knowing how to calculate and verify
medication dosages are essential skills for medical assistants. How often and what kinds

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of medications medical assistants will administer varies by practice setting, but these
principles will help in discussions with patients about taking their medications at home.
Patients might find measuring medications—especially liquid oral and injectable ones—
challenging and need assistance.
Metric System
Most medication prescriptions and dosages will be in the metric system of weights and
volume. However, some medication formulations in the apothecary and standard
systems require conversions. Also, some prescriptions require dosage calculations
based on a patient’s weight in kilograms, especially for pediatric doses. So medical
assistants need a working knowledge of conversions and calculations.
Prescriptions do not usually include length measurements, but there are exceptions. For
example, the amount of nitroglycerin ointment to squeeze onto the application paper is
a length measurement. Metric lengths are common in other clinical applications
(measurements of wounds, distances to use in procedures).
The equivalency tables show the relationship various metric measurements have with
each other.

Equivalency
UNIT RELATIONSHIP TO BASE UNIT DECIMAL VALUE/WHOLE NUMBER

micro- ÷ 1,000,000 0.000001

milli- ÷ 1,000 0.0001

centi- ÷ 1,00 0.01

base unit 1 1

kilo- × 1,000 1,000

Standard System
Standard, or household, measurements of medications are still common, especially for
liquid oral medications taken at home. Many liquid medications come with measuring
cups with marked household and metric equivalents. Still, patients could misplace the
cups and ask about using a teaspoon or tablespoon to measure the dosage. The table
shows the most common equivalents for liquids and weight in this system.

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Standard System
HOUSEHOLD VALUE METRIC EQUIVALENT

15 drops (gtt) 1 mL

1 teaspoon (tsp) 5 mL

1 tablespoon (tbsp) 15 mL

1 fluid ounce (oz), 2 tbsp 30 mL

1 cup 240 mL

1 pint 480 mL (about 500 mL)

1 quart 960 mL (about 1 L)

1 gallon 3,830 mL

2.2 pounds (lb) 1 kilogram (kg)

Dosage Calculations
With all dosage calculations, always take time and recheck calculations. If there is any
doubt, ask the provider or another medical assistant to check the calculations. The
patient’s well-being depends on accuracy in all calculations.
Ratio and Proportion
For calculating adult dosages, the proportion method works well.
For example, a provider prescribes diphenhydramine 50 mg for a patient who is having
a mild allergic reaction. Available are 25 mg capsules. Here is how to determine how
many capsules to give the patient.
If 25 mg equals 1 capsule (cap), then 50 mg equals how many (X) capsules?

25 𝑚𝑚𝑚𝑚 50 𝑚𝑚𝑚𝑚
=
1 𝑐𝑐𝑐𝑐𝑐𝑐 𝑋𝑋 𝑐𝑐𝑐𝑐𝑐𝑐

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Cross-multiply and get the following.

1 × 50 = 25X

50 = 25X
Then divide both sides of the equation by 25, and the result is 2 capsules.
Desired Over Have
Another common method for dosage calculation is the formula method, or desired over
have. This involves thinking of the calculation as to what to give divided by what you
have times the quantity you have. So, for that same prescription for diphenhydramine,
the equation looks like this.

𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷
𝑥𝑥 𝑄𝑄𝑄𝑄𝑄𝑄𝑄𝑄𝑄𝑄𝑄𝑄𝑄𝑄𝑄𝑄 = 𝑋𝑋
𝐻𝐻𝐻𝐻𝐻𝐻𝐻𝐻

50 𝑚𝑚𝑚𝑚
𝑥𝑥 1 𝑐𝑐𝑐𝑐𝑐𝑐 = 𝑋𝑋
25 𝑚𝑚𝑚𝑚

50
𝑥𝑥 1 = 2 𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐
25

Pediatric Dosage Calculations

The most accurate method to determine medication dosage calculations for children is
to use weight calculations.
Dosage by Weight
A provider prescribes diphenhydramine 5 mg/kg/day divided into four doses per day
for a child who weighs 88 lb. Available is diphenhydramine oral liquid 12.5 mg in 5 mL.
How much should the child receive per dose?
First, convert the child’s weight to kg.

2.2 𝑙𝑙𝑙𝑙 88 𝑙𝑙𝑙𝑙

=
1 𝑘𝑘𝑘𝑘 𝑋𝑋 𝑘𝑘𝑘𝑘

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Cross-multiply and get the following.

1 × 88 = 2.2X

88 = 2.2X
Divide both sides of the equation by 2.2, and the equivalent is 40 kg. Multiply 5 mg by
40 kg to determine the daily dose.
5 mg × 40 kg = 200 mg/day
Divide the daily dose into four doses.

300 𝑚𝑚𝑚𝑚
= 50 𝑚𝑚𝑚𝑚/𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑
4

Then use either method to determine the amount of liquid medication to give the child.
If 12.5 mg equals 5 mL, then 50 mg equals how many (X) mL?

12.5 𝑚𝑚𝑚𝑚 50 𝑚𝑚𝑚𝑚

=
5 𝑚𝑚𝑚𝑚 𝑋𝑋 𝑚𝑚𝑚𝑚

Cross-multiply and get the following.

5 × 50 = 12.5X

250 = 12.5X
Divide both sides of the equation by 12.5, and the result is 20 mL.
Body Surface Area
Body surface area (BSA) is widely considered the most accurate way to calculate the
dose based on weight for children up to age 12. The provider might calculate BSA
using a nomogram and then use a formula to determine the pediatric dosage. Several
formulas can be used to figure out the dose. The following is an example.

𝐵𝐵𝐵𝐵𝐵𝐵 𝑜𝑜𝑜𝑜 𝑐𝑐ℎ𝑖𝑖𝑖𝑖𝑖𝑖 𝑖𝑖𝑖𝑖 𝑚𝑚2

𝑥𝑥 𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎 𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑 = 𝑐𝑐ℎ𝑖𝑖𝑖𝑖𝑑𝑑′ 𝑠𝑠 𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑
1.7 𝑚𝑚2

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For example, using a BSA of 0.7 and an adult dose of 50 mg.

0.7 𝑚𝑚2
𝑥𝑥 50 𝑚𝑚𝑚𝑚 = 20.5 𝑚𝑚𝑚𝑚
1.7 𝑚𝑚2

20.5 mg is the child’s dose (follow the rounding rules of the facility)
Conversions and Formulas
There are several methods for converting one measurement to another within or
between measurement systems. Within systems, simple arithmetic is usually sufficient.
For example, if a provider prescribes 0.088 mg levothyroxine and the medication comes
in mcg, the conversion is simple. There is a three-decimal-point difference between mg
and mcg. Because the conversion is from a larger value (mg) to a smaller value, the
decimal point moves three places to the right.
0.088 × 1,000 = 88 mcg
The proportion method works well for other conversions between systems. This involves
thinking of the conversion like this. If 2.2 lb equals 1 kg, then the number of pounds to
convert, 66 lb, equals how many (X) kg? Another way to accomplish this calculation is to
divide the weight in pounds by 2.2 (because 1 kg = 2.2 lb).
If a patient weighs 66 lb, how many (X) kilograms is this?
1 kg = 2.2 lb, therefore:

66 𝑙𝑙𝑙𝑙
= 30 𝑘𝑘𝑘𝑘
1 𝑘𝑘𝑘𝑘

Or:

2.2 𝑙𝑙𝑙𝑙 66 𝑙𝑙𝑏𝑏

=
1 𝑘𝑘𝑘𝑘 𝑋𝑋 𝑘𝑘𝑘𝑘

Cross-multiply and get the following.

1 × 66 = 2.2X

66 = 2.2X

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Then divide both sides of the equation by 2.2, and the result is 30 kg.
Here is another example.
The dosage of the medication is 15 mL, but the patient wants to measure it in
teaspoons. If 5 mL equals 1 tsp, then 15 mL equals how many (X) tsp?

5 𝑚𝑚𝑚𝑚 16 𝑚𝑚𝑚𝑚
=
1 𝑡𝑡𝑡𝑡𝑡𝑡 𝑋𝑋 𝑡𝑡𝑡𝑡𝑡𝑡

Cross-multiply and get the following.

1 × 15 = 5X

15 = 5X
Then divide both sides of the equation by 5, and the result is 3 tsp.

Forms of Medication
Medications are available in a variety of formulations.

Common Medication Formulations

FORMULATIONS ROUTE

Aerosols Inhalation

Caplets Oral

Capsules Oral

Creams Topical, vaginal, rectal

Drops Otic, ophthalmic, nasal

Dry powder for inhalation Inhalation

Elixirs Oral

Emulsions Oral

Foams Vaginal

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FORMULATIONS ROUTE

Gels Oral, topical, rectal

Injectable liquids IV, IM, subcutaneous, ID

Liniments Topical

Lotions Topical

Lozenges Oral

Mist Inhalation, nasal

Ointments Topical, ophthalmic, otic,

vaginal, rectal

Patches Topical

Powders Topical

Powders for IV, IM, subcutaneous, ID

reconstitution

Solid extracts, fluid Oral

extracts

Solutions Oral, topical, vaginal, urethral,

rectal

Sprays Topical, nasal, inhalation,

sublingual

Steam Inhalation

Suppositories Vaginal, rectal

Suspensions Oral

Syrups Oral

Tablets Oral, buccal, sublingual,

vaginal

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FORMULATIONS ROUTE

Tinctures Oral, topical

Look-Alike and Sound-Alike Medications

Be careful when handling and administering medications that have names or labels that
look or sound alike. It is mandatory to check the medication label against the
prescription to avoid making potentially serious medication errors.
Perform three checks before administering any medication.
Check the medication against the prescription when the medication is selected.
Check the medication and prescription when preparing the dose.
Recheck the medication before restocking the bottle.
Make every effort to store these medications away from each other or add a labeling
system to point out the extra caution staff should use when administering these
medications. Often, a medication’s brand name might be similar to another
medication’s generic name, such as clonidine and the brand name of clonazepam,
Klonopin. Other pairs that can cause confusion are hydroxyzine and hydralazine or
hydrocodone and hydromorphone.
For an extensive list of look-alike and sound-alike medications, see the tools section of
the Institute for Safe Medication Practices website.

Routes of Medication Administration

Medical assistants use and discuss many different routes for using medications with
patients. Providers must include the route of administration on every prescription to
avoid undesirable effects that can occur with giving medication by the wrong route.
Medical assistants do not give medications by routes that require nurses or providers:
intravenous, epidural, intrathecal, and others.

Nonparenteral Routes
ROUTE LOCATIONS MEDICATION FORMULATION

Oral Mouth, stomach, intestines Mouth, stomach, intestines

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Common Parenteral Routes for Medications—Injectable

ROUTE LOCATIONS MEDICATION FORMULATION

Intradermal Skin of the upper chest, forearms, Injectable liquid

upper back

Intramuscular (IM) Deltoid, vastus lateralis, Injectable liquid

ventrogluteal muscles

Subcutaneous (SQ or Sub- Upper arms, abdomen, buttocks, Injectable liquid

Q) upper outer thighs

Common Parenteral Routes—Noninjectable

ROUTE LOCATIONS MEDICATION FORMULATION

Topical On the skin Gels, tinctures, solutions,

ointments, lotions, creams,
liniments, powders, patches,
sprays

Vaginal/rectal Vagina/vulva, rectum/anus Suppositories, solutions,

creams, ointments, gels,
foams

Pharmacokinetics (Absorption, Distribution, Metabolism, Excretion)

Pharmacokinetics is the study of how medications move through the body.
Understanding the four actions pharmacokinetics involves—absorption, distribution,
metabolism, and excretion—helps with understanding a medication’s onset of activity,
the peak time of its effects, and how long its effects will last.
Absorption
Through the process of absorption, the body converts the medication into a form the
body can use and moves it into the bloodstream. For example, oral tablets or capsules
move through the stomach or intestines to be absorbed. Oral liquids are absorbed the
same way but have faster absorption because the fluids in the stomach do not have to
break them down into an absorbable form.
The process of absorption also varies with the route. With IV administration, the
medication goes directly to the bloodstream, so the onset of action is much quicker
than other routes, which must first go through other systems, such as the skin or airways.

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At least some of every medication, even those for application on a skin rash or as eye
drops, can end up in the bloodstream.
The speed of absorption depends on other factors as well, such as how easily the
medication dissolves in fat. Medications that are highly fat-soluble pass more readily
through cell membranes into the blood. Medications injected into muscle tissue are
absorbed more quickly by the body due to blood circulation throughout the skeletal
muscle. Another factor is the surface area available for absorption. The stomach has a
smaller inner surface area than the intestines, so intestinal absorption is faster. Food
slows the absorption of many medications and can inactivate some medications.
Medications negatively affected by the gastrointestinal system require parenteral
administration, such as by injection.
Distribution
Distribution is the transportation of the medication throughout the body. The
bloodstream carries the medication to the body’s tissues and organs. There are some
barriers to medication distribution. The blood-brain barrier protects the brain from
dangerous chemicals but can also make it difficult to get some therapeutic substances
into brain tissues. On the other hand, some medications cross the placental barrier very
easily, which is why many medications are risky for pregnant patients.
Metabolism
Metabolism changes active forms of the medication into harmless metabolites ready for
excretion through urine or feces. The liver is the primary organ of metabolism, but the
kidneys also metabolize some medications.
Many factors affect the ability to break down the chemicals in medications. These
include the patient’s age, how many medications they take, the health of various organs
and tissues, and even genetic makeup.
Infants and older adults have the least efficient metabolism, so medication dosages
must be modified to compensate for this variation.
Excretion
Excretion is the removal of a medication’s metabolites from the body. The kidneys
accomplish most of this through urine, but feces, saliva, bile, sweat glands, breast milk,
and even exhaled air eliminate some medications. A medication’s half-life is how long it
takes for the processes of metabolism and excretion to eliminate half a dose of a
medication. Some medications have very short half-lives, such as a few minutes, while
others take days to leave the body. Knowledge of half-lives helps determine dosing
intervals. If a patient does not receive the next dose before the half-life time, the
therapeutic level of the medication will be too low (below the therapeutic range) to be
effective.

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Rights of Medication Administration

The rights of medication administration are a collection of safety checks that everyone
who administers medications to patients must perform to avoid medication errors.
Right Patient
Medical assistants should use two patient identifiers to verify that they are about to
administer medication to the right patient. Then verify that data with the information on
the medical or medication administration records. The most common verification
method is asking patients to state their full name and date of birth. Other acceptable
identifiers, such as a mobile phone number or a photo identification card, pertain only
to that patient.
Right Medication
Check the label three times to verify the medication name, strength, and dose—often
referred to as the “three befores.” This triple-check is essential every time someone
gives a patient medication.
The first time to check the medication label is when taking the medication container
from the storage cabinet or drawer.
The second is when taking the medication from its container to prepare to administer it.
The third check is when putting the container back in storage or discarding it.
While checking the label, check the medication’s expiration date to ensure it has not
expired. Otherwise, the medication might be ineffective or even dangerous due to
factors such as bacterial contamination. Never administer expired medication, and
always dispose of expired medication according to facility guidelines and protocols.
Right Dose
Compare the dosage on the prescription in the patient’s medical record on the
provider’s order with the dosage on the medication’s label. If the dosage form available
does not match what the provider prescribed, medical assistants must perform the
mathematical calculations for administering the right dosage or find a medication
container with a dosage form that matches the prescription. They must also double-
check any calculations that seem questionable or that they are uncertain about and
have another MA or the provider check them as well.
Right Time
In most office and clinic settings, medical assistants give medications right after the
provider writes the prescription. Nevertheless, it is essential to confirm whether the
medication has any timing specifications, such as the patient having an empty stomach
or waiting several hours after taking another medication (such as an antacid) that might

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interact with the new medication. Make sure to prepare the patient for any immediate
effects of the medication. For example, eye drops that dilate the pupils for an eye
examination cause blurry vision and photophobia (sensitivity to light) after
administration. The patient might not be able to drive until the effects wear off. If the
patient does not have an escort or cannot wait in the facility long enough for the
medication’s effects to wear off, this is the wrong time to administer this medication.
Right Route
Medical assistants must compare the route on the prescription in the medical record
with the administration route they are planning to use. Determine that the route is
appropriate for the patient and that the medication formulation is right for that route.
The correct route of administration can be confirmed with the medication’s product
insert from the manufacturer, the Physicians’ Desk Reference (PDR), or another reliable
medication reference. As dictated by the medication’s manufacturer, the route of
administration must be adhered to.
Right Technique
Medical assistants must know and understand the correct techniques for administering
medications. For example:
When administering an intramuscular injection, the correct angle of insertion of the
needle is 90 degrees.
The correct angle of insertion of an intradermal injection is 10 to 15 degrees.
The correct angle for subcutaneous injections is 45 degrees.
Right Documentation
Always document administering medication after the patient receives it, not before. If
the MA does not administer a medication as prescribed, the documentation must
include this and why the patient did not receive it. Proper documentation includes date,
time, quantity, medication, strength, method and location of administration, lot
number, manufacturer, expiration date, and patient outcome, including any reaction or
adverse effects a patient may have had to the medication, noting that the patient
tolerated it well.

Sources of Medication Information and FDA Regulations

No health care professional can know everything about every medication. Because of
this, medical assistants should have access to reliable, medically approved references
they can refer to easily to find information regarding the medications they give. In
addition to books and online resources, there are phone apps that have extensive
information about thousands of medications. Medical assistants can also find extensive
information in the package inserts that come with medications.

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Physicians’ Desk Reference

Each year, a new edition of the PDR is available. Publishers send free copies to
providers’ offices, and additional copies are available for purchase. It contains current,
detailed information about thousands of medications. The PDR also has a product
identification guide with color photographs of many medications. This is useful when
patients bring medications to the office in secondary medication containers instead of
pharmacy-issued packaging.
Online Medication References
Online sources (manufacturer’s websites, government agencies, other online databases)
are easy to access when medical assistants have questions about a medication or need
more information to share with patients. Use only approved online resources to
research medication information, especially when relating that information to patients.
Consult providers regarding their preferred sites.

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Foundational Knowledge and Basic Science: Nutrition

Nutrition
Dietary Nutrients, Suggested Guidelines, and Food Labels
Nutrients are essential food substances—the organic and inorganic materials the body
needs for energy and cellular activities like growth, repair, disease resistance, fluid
balance, and thermoregulation. Some nutrients, such as vitamins, minerals, and some
amino acids, are essential, meaning the body cannot produce them. For example, some
protein components must come from foods. Nonessential nutrients are those the body
can make. Examples are vitamin D and cholesterol, which do not have to come from the
diet.
The body has to break down all the nutrients in the diet into substances it can use. This
process begins with digestion. Nutrients that contain calories are proteins,
carbohydrates, and fats (lipids). Foods containing calories might contain other nutrients,
but water, vitamins, minerals, and fiber do not contain calories. A balance of these
nutrients in the diet is essential for everyone, especially for children, patients who are
pregnant, and older adults.
Dietary Nutrients and Suggested Guidelines
There are six primary nutrients: water, carbohydrates, protein, fat, minerals, and
vitamins. Below are details about each nutrient group. While previous dietary guidelines
included daily intake recommendations, most resources have moved away from
generalized recommendations. This is because it is now understood, better than ever,
that there is no “one size fits all” recommendation regarding nutrition.
Guidelines have been released for the years 2020 to 2025. With this release, MyPlate
removed all general recommendations for daily intake and replaced them with
information about healthy eating based on life stage. To determine specific daily
guidelines, individuals can go to myplate.gov and enter information to generate
individualized guidelines. These personalized food plans take into account the
following.

• Age

• Sex

• Height

• Weight

• Physical activity level

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Water
The human body is 50% to 80% water. People can survive longer without food than
water. Although almost every food and beverage contains water, it is recommended
that people still drink 2 to 3 L (64 to 96 oz) each day for optimal health.
Water has many functions, including transporting nutrients and oxygen throughout the
body, helping remove waste, regulating body temperature through perspiration, and
providing the basic component of blood and other bodily fluids. The body loses water
throughout the day in urine, stool, sweat, and water vapor in breath—a total of 1,750 to
3,000 mL each day. Ideally, the body needs to balance intake and output, replenishing
fluids the body eliminates with drinking water.
Protein
Proteins are large, complex molecules the body makes from amino acids, which are the
natural compounds that plants and animal foods contain. There are three types of
amino acids.
Essential amino acids are ones the body cannot produce.
Nonessential amino acids are ones the body can make from essential amino acids or as
proteins break down.
Conditional amino acids are not usually essential but might become essential when the
body is undergoing stress or illness.
The body uses amino acids from proteins to repair and build tissues. They can also be
used for energy if other sources (carbohydrates and fats) are unavailable. Using protein
for energy is wasteful because, over time, the body will lose lean tissues, and muscle
strength will diminish. Proteins also contribute to the body’s structure, fluid balance,
and creation of transport molecules. Each gram of protein provides four calories. Too
little protein causes weight loss, malnutrition, fatigue, and increased susceptibility to
infection. Too much protein will wind up as body fat or be converted to glucose. The
body requires additional protein when recovering from burns, major infections, major
trauma, and surgery. Additional protein is also important during pregnancy,
breastfeeding, infancy, and adolescence.
Carbohydrates
Carbohydrates are organic compounds that combine carbon, oxygen, and hydrogen
into sugar molecules and come primarily from plant sources. Carbohydrates comprise
the majority of calories in most diets. Depending on their structure, they are either
simple sugars (honey, candy, cane sugar) or complex carbohydrates (fruits, vegetables,
cereal, pasta, rice, beans, whole-grain products).

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The body uses carbohydrates primarily for energy for its cells and all their functions.
Glucose is the simple sugar the body requires for energy needs, and the body burns it
more completely and efficiently than it does protein or fat.
Through digestion, the body converts all other digestible carbohydrates into glucose.
When the supply of glucose exceeds the demand, the body stores glucose in the liver
as glycogen, a ready energy source when the body needs it. Each gram of carbohydrate
provides four calories. Too little carbohydrate in the diet results in protein loss, weight
loss, and fatigue. Too much can lead to weight gain and tooth decay.
Fats
Fats, or lipids, are a highly concentrated source of energy the body can use as a backup
for available glucose. Fat molecules contain fatty acids.
Chemically, the distinctions between fatty acids and the types of fats they form are
complex. For dietary purposes, the important difference is the degree of saturation.
Unsaturated fatty acids are less dense and heavy. They are oils and have less potential
for raising cholesterol levels (thus causing heart disease) than saturated fats.
Unsaturated fats can be monounsaturated (olive, canola, and peanut oil) or
polyunsaturated (corn, sunflower, and safflower oil).
Trans fat is a fatty acid used to preserve processed food products. It is a byproduct of
solidifying polyunsaturated oils (a process called hydrogenation) and raises LDL (“bad”)
cholesterol levels.
Saturated fats are solid at room temperature. Primarily from meat products as well as
palm and coconut oil, this type of fat also raises LDL. There is no cholesterol in other
plant foods.
Fat is an important nutrient that is essential for the absorption of fat-soluble vitamins.
Fats provide structure for cell membranes, promote growth in children, maintain healthy
skin, assist with protein functions, and help form various hormone-like substances that
have important roles, like preventing blood clots and controlling blood pressure. Stored
fat has the protective function of insulating and protecting organs. Each gram of fat
provides nine calories. Too little fat can cause vitamin deficiencies, fatigue, and dry skin.
Too much fat can cause heart disease and obesity.
Vitamins
Vitamins are organic substances the body needs for various cellular functions. Each
vitamin has a specific role. Except for vitamins D, A, and B3, the body cannot make
them or cannot make enough of them, so they have to be part of dietary intake to
promote health and avoid deficiencies. Vitamins do not provide energy, but they are
necessary for the body to metabolize energy.

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The major classification of vitamins is according to their solubility. This means that their
absorption, transportation, storage, and excretion depend on the availability of the
substance in which they dissolve.
Fat-soluble vitamins: A, D, E, K
Water-soluble vitamins: B1, B2, B3, B6, folate, B12, pantothenic acid, biotin, C
Minerals
Minerals are inorganic substances the body needs in small quantities for building and
maintaining body structures. They are essential for life because they contribute to many
crucial life functions, like those of the musculoskeletal, neurological, and hematological
systems. They provide the rigidity and strength of the bones and contribute to muscle
contraction and relaxation. They also help regulate the body’s acid-base balance and
are essential for normal blood clotting and tissue repair. They are cofactors for
enzymes, which means they assist those substances in performing their metabolic
functions.

Nutrient Food Sources

NUTRIENT EXAMPLES OF FOOD SOURCES

Water Plain water

Vegetables
Fruit

Protein Meat, poultry, and fish

Cooked beans
Eggs
Nuts, seeds, nut butters

Carbohydrates Whole grains

Vegetables
Fruits
Rice
Beans
Potatoes

Fats Fatty fish (tuna, salmon, sardines)

Avocado
Olive oil

Vitamin A Milk fat, meat, leafy vegetables, egg

yolks, fish oil, orange and yellow fruits

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NUTRIENT EXAMPLES OF FOOD SOURCES

Vitamin B Fish, meat, poultry, whole grains, seeds,

(generalized) nuts, yeast, avocados, bananas

Vitamin C Berries, citrus fruits, green peppers,

mangoes, broccoli, potatoes,
cauliflower, tomatoes

Vitamin D Sunlight, fortified milk, eggs, fish, liver

Vitamin E Fortified cereal, nuts, vegetable oils,

green and leafy vegetables

Folate Green and leafy vegetables, beans,

asparagus, legumes

Vitamin K Green and leafy vegetables, dairy

products, grain products, meat, eggs,
fruits

Pantothenic acid Meat, grains, legumes, fruits,

vegetables

Sodium Beef, pork, sardines, cheese, green

olives, sauerkraut

Potassium Whole and skim milk, bananas, prunes,

raisins

Calcium Milk and milk products, meat, eggs,

cereals, beans, fruits, vegetables

Phosphorus Milk, cheese, meat, poultry, cereals,

nuts, legumes

Magnesium Green leaves, nuts, cereal grains,

seafood

Iron Soybean flour, beef, beans, clams,

peaches

Iodine Seafood, iodized salt, dairy products

Zinc Vegetables

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Food Labels
To succeed in following strict guidelines for nutritional modifications (low sodium,
adequate potassium), patients need to understand and use food labels. Reading food
labels routinely can be a surprising realization of what is actually being consumed by the
body.
The USDA requires food products to contain labels containing details about their
contents. These nutritional facts must include specific elements.

• Serving size

• Calories per serving

• Grams of different types of fat

• Amounts of sodium, potassium, cholesterol, total carbohydrates, sugar, and

protein

• Percentage of recommended daily values for some vitamins and minerals

Other information is voluntary, and requirements change from time to time.
When showing patients how to read food labels, emphasize that they should check the
serving size and number of servings in the package. It is easy to mistake the list of
calories and nutrients as the amount in the entire container when it might only be a
small percentage of the container. Consider a bottle of a sports drink. After strenuous
activity, thirst might dictate drinking the whole container, with the person thinking the
amounts of sugar and sodium are reasonable. On closer inspection, those amounts are
for one serving, and the bottle contains three servings.
Serving sizes often vary by manufacturer. These variations can be deceptive, so prepare
patients to compare labels critically when choosing a food product. Also, check
ingredient lists. The ingredients begin with the one the product contains the most of
and then others in descending order.
Emphasize the components that are especially important for each patient’s situation.
Patients who are at risk for or have heart disease should be cautious about sodium and
cholesterol. On the other hand, patients at risk for bone loss will want to check calcium
amounts and opt for choices to increase their dietary calcium intake.

Vitamins and Supplements

Vitamins and supplements are extremely common and are marketed to consumers as
an easy way to improve health. The reality is that the best source of vitamins and
nutrients needed for healthy living comes from whole foods, though many people take
vitamin supplements in addition to their diet. The FDA monitors herbal and other

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supplements with much looser guidelines and monitoring than over-the-counter

medications.
Patients should discuss any new vitamins or supplements with their provider before
taking them. When reviewing medication lists during patient intake and the patient
interview, ask about vitamin and supplement usage and document anything the patient
takes. There can be dangers associated with taking them, such as interactions with
prescription medications or negative impact on chronic conditions. A provider may
recommend a supplemental vitamin, especially if the patient has a condition that
reduces the ability to process that vitamin from natural food sources.

Common Vitamins and Supplements: Intended Benefits and Safety

Considerations
VITAMIN/SUPPLEMENT FUNCTION/INTENDED BENEFIT SAFETY CONSIDERATIONS

Vitamin A Night vision, cell growth and Toxicity can occur if levels are too
maintenance, the health of the high, leading to headaches, peeling
skin skin, and bone thickening.

Vitamin D Calcium absorption, bone and Toxicity can occur if levels are too
tooth health, heart and nerve high, leading to kidney failure,
function metastatic calcification, and
anorexia.

Vitamin E Protection of cells (including skin N/A

and brain), formation of blood
cells

Vitamin K Blood clotting, bone growth Can counteract blood clotting

medications, reducing their
efficiency

Vitamin B1 Carbohydrate metabolism, heart, N/A

nerve, and muscle function

Vitamin B2 Fat and protein metabolism N/A

Vitamin B3 Carbohydrate and fat metabolism Toxicity can occur if levels are too
high, leading to red, itching skin
with tingling.

Vitamin B6 Enzyme assistance in the amino Toxicity can occur if levels are too
acid synthesis high, leading to peripheral
neuropathy.

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VITAMIN/SUPPLEMENT FUNCTION/INTENDED BENEFIT SAFETY CONSIDERATIONS

Vitamin B12 Protein and fat metabolism, N/A

nerve-cell maintenance, cell
development

Vitamin C Immunity, iron absorption, the N/A

structure of bones, muscle, and
blood vessels

St. John’s wort Treatment for depression, anxiety, Some studies found it ineffective in
and sleep disorders its intended benefits (similar results
to a placebo).
No long-term safety studies have
been conducted.

Black cohosh Relief of menopause symptoms, Large doses can cause vomiting,
including hot flashes, night dizziness, and headaches.
sweats, headaches, heart Long-term studies have yet to be
palpitations, and mood changes conducted (recommended to take
for less than 6 months).

Melatonin Melatonin is a naturally occurring Can result in drowsiness and

hormone in the brain. Also can be headaches
taken as a supplement to May interfere with conception
potentially help with sleep
regulation and combat aging
(studies validate the support of
sleep regulation but do not
support anti-aging benefits).

Willow bark Pain relief (one of the main Do not exceed 240 mg/day
ingredients of aspirin comes from Not safe for those who cannot
willow bark) tolerate aspirin

Glucosamine sulfate Promote healthy cartilage No safety concerns

formation to maintain or replace Recent studies found glucosamine
wear and tear on joints sulfate to be no more effective than
a placebo in knee osteoarthritis.

Gingko biloba Improve memory and mental Extremely high doses can lead to
function by increasing blood flow nausea, vomiting, and diarrhea.
to the brain

Dietary Needs Related to Diseases and Conditions

In addition to factors such as age, sex, height, and weight, certain diseases also need to
be considered when considering a healthy diet. When coaching a patient on nutrition,

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the patient’s provider should approve recommendations to ensure they align with the
patient’s chronic conditions and treatment plans.
Dietary Needs for Diabetes
Type II diabetes is a chronic condition often connected to an individual’s food intake. In
the most general terms, diabetes is defined by the body’s inability to turn food into
energy properly. If caught and managed early, it is sometimes possible to entirely
manage diabetes through diet. Over time, the need for medications increases, but
careful blood sugar management through food intake can greatly reduce this need.
The goal of a healthy diet for a person who has diabetes is to control blood sugar
levels, preventing blood sugar from going too high and too low. Careful planning and
managing food intake can promote the stability and consistency of blood sugar.
General dietary guidelines for patients who have diabetes include the following.
Eating several small, nutrient-dense meals consistently throughout the day.
Avoiding or severely limiting foods high in added sugars. Properly balancing blood
sugar is essential when high-sugar foods are consumed.
Limiting foods high in carbohydrates, especially those with refined grains.
Consuming more fiber. Fiber is an essential nutrient to help break down carbohydrates.
The CDC recommends following the plate method for easy diabetes management. The
plate method centers around how to fill up a 9-inch dinner plate.
1/2 of the plate should be non-starchy vegetables, including green, leafy vegetables,
cauliflower, or carrots.
1/4 of the plate should be foods higher in carbs, ideally whole grains or other whole
foods such as peas, potatoes, whole grain rice or pasta, beans, fruit, or yogurt.
1/4 of the plate should be a lean protein such as chicken, turkey, beans, or tofu.
Water is the best choice for a drink, but other zero-calorie (sugar-free) drinks can be
substituted if strongly preferred.
Dietary Needs for Kidney Disease
Chronic kidney disease (CKD) is the gradual decrease in kidney function, and it impacts
millions of Americans. It is most common in older adults as kidney function decreases.
Many people may have early-stage (1 to 3) CKD without knowing it. As kidney function
worsens and reaches stages 4 to 5, symptoms become more apparent, and the impact
is greater. Annual bloodwork can help catch CKD early. Medications are typically not
recommended in early stages, and diet is the primary intervention.

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The U.S. Department of Health and Human Services recommends the following steps
for altering a diet to prevent or mitigate further kidney damage (Note: Steps 1 to 3
should be implemented at any stage of CKD; steps 4 to 5 are most important for those
in late-stage CKD.).

Dietary Modifications for Kidney Disease

STEP ACTION/REASONS OPTIMAL FOOD SELECTIONS

Step 1 Limit salt/sodium. Swap prepared or packaged foods for

High blood pressure is a primary fresh foods to avoid added sodium.
contributing factor to worsened kidney Opt for salt/sodium-free spices to flavor
function. food.
Limiting sodium intake to less than Select foods with less than a 20% daily
2,300 mg/day is optimal for those with value of sodium.
CKD to prevent extra strain on the Rinse canned foods with fresh water
kidneys. before eating or cooking them.

Step 2 Be cautious with protein. Animal proteins

Chicken
Protein is essential in any diet but also
Fish
creates waste, which strains the kidneys.
Meat
Eat protein-rich foods with meals Eggs
Discuss with your provider if animal- Dairy
based or plant-based (or a combination) Plant proteins
proteins are best. Beans
Nuts
Grains

Step 3 Protect your heart. Lean meats

Skinless poultry
Eating heart-healthy foods will help
Fish
prevent fat and cholesterol from
Beans
building up in your heart, blood vessels,
Vegetables
and kidneys.
Low-fat or fat-free milk products

Step 4 Minimize phosphorus intake. Low-phosphorus foods:

As kidney function decreases, kidneys Fresh fruits and vegetables
will no longer effectively filter out excess Bread, pasta, rice
phosphorus levels.
Corn and rice cereals
Excess phosphorus in the blood can
Non-enriched rice milk
damage bones, leading to a higher risk
of fractures, and can also damage blood Higher-phosphorus foods to limit:
vessels. Meat, poultry, fish
Dairy
Bran cereals
Beans, lentils, and nuts

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STEP ACTION/REASONS OPTIMAL FOOD SELECTIONS

Step 5 Control potassium levels. Lower-potassium foods:

Severe kidney damage can lead to Apples
increased potassium in the bloodstream. Peaches
Potassium levels that are too high or too White bread and pasta
low can be very dangerous and
White rice
damaging to the heart, muscles, and
nerves. Non-enriched rice milk
Understanding potassium levels in food Higher-potassium foods:
and discussing dietary changes related Oranges
to potassium with a doctor are essential Bananas
in late-stage CKD.
Brown and wild rice
Bran cereals
Dairy
Whole-wheat bread and pasta
Beans and nuts

Source: https://www.niddk.nih.gov/health-information/kidney-disease/chronic-kidney-disease-
ckd/prevention

Dietary Needs for Celiac Disease

Celiac disease is an autoimmune disorder in which individuals cannot safely consume
gluten, a protein substance found naturally in wheat, barley, and rye. While many
people may avoid gluten due to its potential to cause unpleasant bloating and
digestion symptoms, those with celiac disease will incur damage to their small intestine
if gluten is consumed. The primary treatment for celiac disease is eating a gluten-free
diet.
Tips from the U.S. Department of Health and Human Services for those with celiac
disease include the following.
Look for foods labeled “gluten-free,” “no gluten,” “free of gluten,” or “without
gluten.”
Avoid foods made with ingredients that naturally contain gluten: wheat, barley, and rye.
Be cautious of the following.

• Baked goods

• Baking mixes

• Alcohols

• Malt vinegar

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• Additives and flavorings

Be cautious of cross-contact, especially when eating out at a restaurant.
Prepare and store gluten-free foods separately from foods with gluten that other
household members might be consuming.
Opt for naturally gluten-free foods whenever possible, including the following.

• Meat

• Fish

• Fruits and vegetables

• Rice

• Potatoes

• Flour made from gluten-free foods, such as quinoa, buckwheat, soy, and nuts

Eating Disorders
Medical assistants are likely to encounter patients who have eating disorders, which are
food patterns that can impair health and well-being. The most common are anorexia
nervosa, bulimia nervosa, and binge-eating disorder.
Anorexia
Anorexia nervosa affects people of all ages, genders, and races. Characteristically,
patients are high achievers who exert severe control over their eating patterns. Often,
there is a family history of anorexia and alcohol use disorder. Some patients have
histories of childhood trauma, depression, major life changes, and high stress levels.
Warning signs and symptoms of anorexia nervosa include the following.

• Self-starvation

• Perfectionism

• Extreme sensitivity to criticism

• Excessive fear of weight gain

• Weight loss of at least 15%

• Amenorrhea (no menstrual periods)

• Denial of feelings of hunger

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• Excessive exercising

• Ritualistic eating behavior

• Extreme control of behavior

• Unrealistic image of the self as obese

Medical assistants who observe or suspect any of these manifestations should alert the
provider immediately, as this disorder can be life-threatening. Treatment involves
hospitalization with parenteral nutrition or nasogastric feedings, plus psychotherapy.
Educating the patient and family about nutrition is also essential.
Bulimia
Bulimia nervosa involves eating large amounts of food (binging) and then purging by
self-induced vomiting, laxatives, or diuretics. It is controlling behavior, usually aimed at
gaining control of weight. Sometimes it is caused by gaining some weight and dieting
unsuccessfully to lose weight. People who have bulimia can feel guilty when they
overeat or eat high-calorie foods and then attempt to alleviate the guilt by eliminating
the food they eat. People who have this disorder often define their value as being thin
and might previously have been thin. For a variety of reasons, they cannot control their
eating habits. Those who seek treatment are most often in their 20s.
Warning signs and symptoms of bulimia nervosa include the following.

• Buying and consuming large amounts of food

• Purging after eating excessive amounts of food

• When dining with others, using the bathroom immediately after eating

• Using laxatives and diuretics

• Keeping weight constant while overeating fattening foods

• Mood swings

• Depression and guilt after binging and purging

Medical assistants who observe or suspect any of these manifestations should alert the
provider immediately. Although this disorder is not life-threatening, it can cause lesions
in the esophagus, erosion of tooth enamel, and electrolyte and hormone imbalances.
Treatment involves psychotherapy, medication for anxiety and depression, dental work,
nutrition counseling, and support groups.

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Binge Eating
Binge eating disorder is similar to bulimia nervosa, without the purging behavior. With
this disorder, people chronically overeat. The major manifestation is weight gain and
obesity. Obesity increases the risk of heart disease, hypertension, type 2 diabetes
mellitus, stroke, cancer, joint disorders, GERD, and sleep apnea. People who are obese
often have heartburn, bloating, abdominal pain, diarrhea, and other gastrointestinal
problems. With binge eating disorder, patients do not restrict their diet between
bingeing episodes, often eat quickly until they are uncomfortably full, eat when not
hungry, and eat alone due to feelings of shame and guilt about overeating. Food
becomes an addiction or a coping mechanism, predisposing patients to alcohol and
substance use disorders.
Medical assistants who suspect this disorder should alert the provider immediately.
Treatment involves focusing on eating healthy food, self-acceptance, awareness of
hunger and fullness, and engaging progressively in enjoyable physical activity. For
some, keeping a food diary helps provide a realistic picture of how much food they
consume. Discussion with a counselor about their feelings and emotions about eating
can also help. Psychotherapy is effective in reducing the frequency and severity of binge
episodes.

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Foundational Knowledge and Basic Science: Medical Terminology

Medical Terminology
Learning medical terminology might seem as daunting as learning another language. In
a way, it is another language. When toddlers first start speaking actual words, they do
not yet know what geography, philanthropy, or accountability mean. But with
experience in listening and speaking, they learn to use and understand more words.
They later notice connections among words—their prefixes, roots, and suffixes. As their
vocabulary continues to expand, children usually master communication in their native
language.
Medical assistants become fluent in medical terminology in much the same way, with
one distinct advantage. They will first learn the basics in coursework and with learning
activities such as this module. Here are the most common terms, abbreviations,
acronyms, and symbols needed to begin to navigate communication in this new career.
Learning how to dissect some terms into their prefixes, roots, and suffixes can also
expand understanding of terminology much faster than learning each word individually,
fast-tracking to mastery in medical terminology.

Common Abbreviations, Acronyms, and Symbols

Medical assistants see and use many abbreviations (a term that will refer here to
symbols as well) in everyday practice. The Joint Commission (TJC) and the Institute for
Safe Medication Practices (ISMP) have put some abbreviations on their “Do Not Use”
and “Error-Prone Abbreviations” lists. Avoiding these abbreviations is essential because
of their potential for misunderstanding and medical errors. The following table includes
many abbreviations that should not be used. (For the full lists, go to The Joint
Commission and ISMP websites.)

DO NOT USE USE INSTEAD

MS, MSO4 Morphine

MgSO4 Magnesium sulfate

Abbreviated medication name Full medication name

Nitro Nitroglycerin

u, U, IU Units

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DO NOT USE USE INSTEAD

x3d mcg or microgram

cc mL

Apothecary units Metric units

od, O.D., OD Daily or intended time of administration

q.d, qd, Q.D, QD, q1d, i/d Daily

q.o.d., QOD Every other day

Q6PM 6 p.m. daily

TIW, tiw 3 times weekly

HS half-strength, bedtime (hour of sleep)

SC, SQ, sub q subcutaneously

IN intranasal

IJ injection

OJ orange juice

@ at

&, + and

/ per

AD, AS, AU right ear, left ear, both ears

OD, OS, OU right eye, left eye, both eyes

D/C, dc, d/c discharge or discontinue

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Abbreviations
Many other abbreviations are facility-specific but not universal. For example, one
hospital might call its storage and processing area for medical products “central
supply,” while another might call it “materials management.” So, “CS” has no meaning
(or a different meaning) in Hospital B, and “MM” has no meaning (or a different
meaning) in Hospital A. Likewise, Hospital A calls the surgery area the operating room
(OR), while Hospital B calls it the surgical suite (SS). Yet another hospital uses “SS” to
mean its department of social services.
Many acronyms go back to long-outdated usage. “Emergency room” became common
parlance when there was literally one room—an emergency or accident room. Even
though today’s hospitals have an enormous emergency department (ED), “ER” is still in
prevalent use today. Other terminology changes over time. What was once the recovery
room (RR) is now the post-anesthesia care unit (PACU).
There are many common abbreviations that reflect current clinical practice and are
primarily universal. Providers use many of these when writing orders, often on
prescription pads, for diagnostic tests and procedures. Here is a list of many of those
common abbreviations.

Common Abbreviations and Acronyms

ABBREVIATION/ ABBREVIATION/
ACRONYM MEANING ACRONYM MEANING

Abd Abdomen C Celsius

ABGs Arterial blood gases C&S Culture and sensitivity

a.c. Before meals Ca Calcium; cancer

ACLS Advance cardiac life support CABG Coronary artery bypass graft

Ad lib As desired CAD Coronary artery disease

ADHD Attention deficit CBC Complete blood count

hyperactivity disorder

AKA Above-the-knee amputation CC Chief complaint

AMA Against medical advice CDC Centers for Disease Control

and Prevention

ASA Aspirin cm Centimeter

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ABBREVIATION/ ABBREVIATION/
ACRONYM MEANING ACRONYM MEANING

ASAP As soon as possible CMS Centers for Medicare and

Medicaid Services

BE Barium enema CNS Central nervous system

BKA Below-the-knee amputation CP Chest pain

BM Bowel movement CPR Cardiopulmonary

resuscitation

BMI Body mass index c/o Complains of

BP Blood pressure COPD Chronic obstructive

pulmonary disease

BPH Benign prostatic Csf Cerebrospinal fluid

hypertrophy

BPM Beats per minute CT Computed tomography

BRP Bathroom privileges Cv Cardiovascular

BSA Body surface area CVA Cerebrovascular accident

(stroke)

BUN Blood urea nitrogen CXR Chest x-ray

Bx Biopsy d Day

c̄ With D&C Dilation and curettage

D/C, dc Discharge, discontinue HIV Human immunodeficiency

virus

DM Diabetes mellitus HPV Human papillomavirus

DNR Do not resuscitate HTN Hypertension

DOB Date of birth Hx History

DTap Diphtheria, tetanus, and I&D Incision and drainage

acellular pertussis vaccine

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ABBREVIATION/ ABBREVIATION/
ACRONYM MEANING ACRONYM MEANING

Dx Diagnosis I&O Intake and output

ECG, EKG Electrocardiogram ICU Intensive care unit

ED Emergency department IUD Intrauterine device

EEG Electroencephalogram K Potassium

ENT Ear, nose, and throat KUB Kidneys, ureters, bladder

F Fahrenheit L Liter or left

FBS, FBG Fasting blood sugar/glucose lb Pound

f/u Follow up LLE Left lower extremity

FUO Fever of unknown origin LLL Left lower lobe

Fx Fracture LLQ Left lower quadrant

GI Gastrointestinal LMP Last menstrual period

GTT Glucose tolerance test LUE Left upper extremity

gtt Drop LUQ Left upper quadrant

GU Genitourinary Mg/dl Milligrams per deciliter

GYN Gynecology, gynecologist MI Myocardial infarction

H, hr Hour mL Milliliters

Hct Hematocrit MM Mucous membrane

HEENT Head, ears, eyes, nose, mm Hg Millimeters of mercury

throat

HF Heart failure MRI Magnetic resonance imaging

Hgb Hemoglobin MS Multiple sclerosis

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ABBREVIATION/ ABBREVIATION/
ACRONYM MEANING ACRONYM MEANING

HIPAA Health Insurance Portability N/V Nausea/vomiting

and Accountability Act

NB Newborn RLL Right lower lobe

NG Nasogastric RLQ Right lower quadrant

NKA/NKDA No known allergies/No R/O Rule out

known drug allergies

NPO Nothing by mouth (nil per ROM Range of motion

os)

NS Normal saline RT Respiratory

therapy/therapist

NSAID Nonsteroidal anti- RUE Right upper extremity

inflammatory drug

OB Obstetrics RUQ Right upper quadrant

OC Oral contraceptive Rx Prescription

OOB Out of bed s̄ Without

OP Outpatient SOB Shortness of breath

OT Occupational Stat Immediately

therapy/therapist

OTC Over-the-counter STI Sexually transmitted

infection

PA Posteroanterior, physician Sx Symptoms

assistant

p.c. After meals (post cibos) T&A Tonsillectomy and

adenoidectomy

PE Physical examination, TB Tuberculosis

pulmonary embolism

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ABBREVIATION/ ABBREVIATION/
ACRONYM MEANING ACRONYM MEANING

PID Pelvic inflammatory disease TIA Transient ischemic attack

PMS Premenstrual syndrome Tx Treatment

PO By mouth UA Urinalysis

PRN As needed URI Upper respiratory infection

PT Physical therapy/therapist UTI Urinary tract infection

pt Patient VS Vital signs

R Right WBC White blood cell

RA Rheumatoid arthritis WNL Within normal limits

RBC Red blood cell YO, y/o Years old

RLE Right lower extremity

Acronyms and Symbols

Some medical symbols have fallen out of use because of their tendency toward
misinterpretation, especially in handwriting. Some of those are on the “Do Not Use”
and “Error-Prone Abbreviations” lists. Examples are the symbols for “greater than” and
“less than” (> and <), as well as those for “greater than or equal to” and “less than
or equal to” (≥ and ≤). Those lists also advise against using @ and &, as people
can mistake them for the numeral 2. Likewise, the plus sign should not be used,
because it can look like the numeral 4. When in doubt, spell it out. Here are a few
symbols that medical assistants might still see in handwritten medical records. These
can also be risky: ↑ could look like the numeral 7, ↓ could look like the
numeral 1, and º could look like the numeral 0.

SYMBOL MEANING

# Pounds, number

↑ Increase

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SYMBOL MEANING

↓ Decrease

♂ Male

♀ Female

‘ Feet

“ Inches

° Degrees

Medical Word Building

As familiarity with medical terminology grows, it becomes easy to notice similarities
among these terms. That is because many of them share common roots, prefixes, and
suffixes. Putting together these components builds many medical terms. However, it
doesn’t work to just mix and match three components and find a word that is in
universal use. For example, hemi- means half, narc means sleep, and -ism means
condition. But a patient chronically getting half the amount of sleep they should get
isn’t heminarcism. There is no such word. Also, with some combinations, the result
requires interpretation, because the literal meaning might vary a little from the actual
meaning. An example is antibiotic, a combination of the prefix anti-, meaning against,
and the word root bio, meaning life. Antibiotics are not incompatible with life. They kill
a particular type of living organism: bacteria. Also, not all medical terms adhere to the
prefix-root-suffix schema. However, looking at a word that has any one of those word
components in it can offer a clue to what the term means.
Word Roots
Word roots are the core component of many words. Medical terms usually have one
root but can have two or more.
For example, hem- means blood, and -rrhage means excessive flow. The “o” between
the two creates the medical term hemorrhage, meaning excessive blood flow. Not all
word roots relate to a body system or a body part, but the following tables lists some of
the terms that do.
Common Word Roots

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Endocrine
WORD ROOT MEANING

Aden Gland

Pancreat Pancreas

Thyr Thyroid gland

Hematologic
WORD ROOT MEANING

Hem, hemat Blood

Phleb Vein

Thromb Clot

Musculoskeletal
WORD ROOT MEANING

Arthr Joint

Brachi Arm

Cervic Neck

Chondr Cartilage

Cost Rib

Crani Skull

Dactyl Finger or toe

Fibr Connective tissue

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WORD ROOT MEANING

My Muscle

Oste Bone

Pod Foot

Sacr Sacrum

Spondyl, vertebr Vertebra

Ten, tendin Tendon

Gastrointestinal
WORD ROOT MEANING

Abdomin Abdomen

An Anus

Appendic Appendix

Bil, chol Bile, gall

Col Colon

Dent Teeth

Enter Intestines

Esophag Esophagus

Gastr Stomach

Gingiv Gums

Gloss Tongue

Hepat Liver

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WORD ROOT MEANING

Icter Jaundice

Ile Ileum

Lapar Abdominal wall

Lingu Tongue

Pancreat Pancreas

Pepsia Digestion

Phag Eating, swallowing

Proct Rectum

Splen Spleen

Stomat Mouth

Genitourinary/Reproductive
WORD ROOT MEANING

Andr Male

Colp Vagina

Cyst Bladder

Gravid Pregnant

Gynec Female

Hyster Uterus

Mamm, mast Breast

Metr Uterus

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WORD ROOT MEANING

Nephr Kidney

Ov Ovum

Oophor Ovary

Orchid Testicles

Prostat Prostate gland

Pyel Pelvis of the kidney

Ren Renal/kidney

Salping Fallopian tube

Ureter Ureters

Ur Urinary

Vesic Bladder

Respiratory
WORD ROOT MEANING

Bronch Bronchial

Laryng Larynx

Nas Nose

Pleur Pleura

Pneum, pneumon Lungs, air

Pulmon Lung

Rhin Nose

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WORD ROOT MEANING

Steth Chest

Thorac Thorax

Trache Trachea

Integumentary

WORD ROOT MEANING

Derm, dermat Skin

Hidr Sweat

Trich Hair

Onych Nail

Xer Dry

Cardiovascular
WORD ROOT MEANING

Angi Blood vessel

Arteri, arter Artery

Cardi Heart

Vas Vessel

Ven Vein

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Neurologic
WORD ROOT MEANING

Blephar Eyelid

Cephal Head

Cerebr Cerebrum

Encephal Brain

Esthesi Sensation

Irid, ird Iris

Mening, meningi Membranes, meninges

Myel Spinal cord, bone marrow

Myring Eardrum

Neur Nerve

Ocul, ophthalm Eye

Ot Ear

Other
WORD ROOT MEANING

Adip Fat

Bio Life

Carcin Cancer

Cry Cold

Dors Back portion of the body

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WORD ROOT MEANING

Gluc, glyc Sugar

Hemi Hernia

Hist Tissue

Hydra Water

Lact Milk

Later Side

Lip Fat

Lith Stone

Med, medi Middle

Narc Numbness, stupor, sleep

Necr Death

Onc Tumor

Path Disease

Ped Child; foot

Psych Mind

Pyo Pus

Pyr Fever, heat

Septic Infection

Therm Heat

Combining Root Words

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Foundational Knowledge and Basic Science: Medical Terminology

A combining form is a word root with a combining vowel. Often, the combining vowel
makes the medical term easier to pronounce. In most cases, the combining vowel is an
“o,” but it is sometimes “i” or “e.” A combining form should be used when the last
word root in a medical term connects with a suffix that begins with a consonant. When
the word root connects with a suffix that starts with a vowel, just the word root should
be used.

Combining Form Examples

COMBINING
WORD ROOT COMBINING VOWEL FORM SUFFIX MEDICAL TERM

Col O Col/o -stomy Colostomy

Cephal O Cephal/o -algia Cephalagia

Col O Col/o -ectomy Colectomy

Cephal O Cephal/o -dynia Cephalodynia

When the suffix begins with a vowel, the word root is used. Examples include
cephalalgia and colectomy. However, when the suffix begins with a consonant, the
combining form is used, as in colostomy and cephalodynia. When connecting two word
roots, always use the connecting vowel, even if the following word root begins with a
vowel.
Prefixes
Prefixes are word components that appear at the beginning of a word to change the
meaning of the rest of the word. They generally mean the same thing in each word they
modify. Some medical terms have no prefix. An example is splenectomy, a combination
of the word root splen, meaning spleen, and the suffix -ectomy, meaning removal. The
following is a list of some of the common prefixes medical assistants will encounter.

Common Prefixes
PREFIX MEANING PREFIX MEANING

A-, an- Without Mega- Exceptionally large

Ab- Away, from Meso- Middle

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Foundational Knowledge and Basic Science: Medical Terminology

PREFIX MEANING PREFIX MEANING

Ad- Toward Meta- Over, beyond

Ambi- Both Micro- Small

Ante- Before Mono- One

Anti- Against Multi- Many

Auto- Self Neo- New

Bi- Two, twice, double Nulli- None

Brady- Slow Peri- Around

Circum- Around Poly- Many

Contra- Against Post- After, behind

De- Down Pre-, pro- Before, in front of

Dys- Painful, abnormal, Presby- Older age

difficult, bad

Endo- Within, inside Primi- First

Epi- Above, on Pseudo-

Eu- Normal, good Quadri- Four

Ex-, extra-, Outside of Retro- Behind, in back of

exo-

Hemi- Half Sten- Narrowed

Hyper- Above, excessive, Sub- Under

increased

Hypo- Below, decreased, Super-, supra- Above, excess

insufficient

Infra- Beneath Sym-, syn- Together, with

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Foundational Knowledge and Basic Science: Medical Terminology

PREFIX MEANING PREFIX MEANING

Inter- Between, among Tachy- Fast

Intra- Within, during Trans- Across

Levo- To the left Tri- Three

Macro- Large Ultra- Beyond, excess

Mal- Bad Uni- One

Suffixes
Suffixes are word components that appear at the end of the word to change the
meaning of the rest of the word. Some medical terms have no suffix, such as appendix.
Some medical terms combine a prefix and a suffix with no word root. An example is
hemiplegia, a combination of the prefix hemi-, meaning half, and the suffix -plegia,
meaning paralysis. The following tables list some of the common general suffixes
medical assistants will encounter, as well as some that are more specific to clinical
disorders and medical, surgical, and diagnostic procedures.
Common Suffixes

General
SUFFIX MEANING

-age Related to

-cidal, -cide Pertaining to killing

-form Shape

-fuge Driving away

-iatry, -iatrist Healing by a provider/healer

-ical Pertaining to

-ion Process

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Foundational Knowledge and Basic Science: Medical Terminology

SUFFIX MEANING

-logy, logist Study of, one who studies

-ole Little, small

-opia Vision

-phylaxis Protection, prevention

-pnea Breathing

-therapy Treatment

-uria Urine

Surgery/Procedures
SUFFIX MEANING

-centesis Surgical puncture

-cise Cut, remove

-clasis Break down

-desis Stabilization, binding

-ectomy Removal, excision

-gram Record

-graph Instrument for recording

-graphy Process of recording

-ion Process

-lepsy Seizure, convulsion

-lysis Destruction, separation

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Foundational Knowledge and Basic Science: Medical Terminology

SUFFIX MEANING

-meter Device for measuring

-metry Process of measuring

-pexy Fixation, to put in place

-plasty Surgical repair, reformation

-scopy Visual examination

-spasm Involuntary twitch

-stasis Stopping or controlling

-stomy A new opening

-tomy Incision

-tripsy Crushing

Disorders/conditions
SUFFIX MEANING

-algia Pain

-asthenia Weakness

-cele Swelling, herniation

-dynia Pain

-ectasis Dilation, expansion

-emesis Vomiting

-emia Blood condition

-gen Producing

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Foundational Knowledge and Basic Science: Medical Terminology

SUFFIX MEANING

-ia, -ism Condition of

-iasis Presence of, formation of

-I Inflammation

-malacia Weakening or softening of

-mania Obsessive preoccupation

-megaly Enlargement

-oid Seeming like

-ole Small

-oma Tumor

-osis Condition, usually abnormal

-pathy Disorder, disease

-penia Deficiency, decrease

-phagia Eating, swallowing

-phasia Speech

-phobia Fear

-plasia Formation of

-plegia Paralysis

-ptosis Drooping, falling

-rrhage Bursting forth

-rrhea Flow, discharge

-rrhexis Rupture

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Foundational Knowledge and Basic Science: Medical Terminology

SUFFIX MEANING

-sclerosis Hardening condition

-trophy Development

Common Terms
Usually, it is best to use lay terms instead of medical terminology when communicating
with patients to ensure patients understand. Develop a knowledge base of lay terms
associated with medical terms to effectively communicate with patients.

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Foundational Knowledge and Basic Science: Medical Terminology

Medical Terms
MEDICAL TERM LAY LANGUAGE

Hypertension High blood pressure

Angina Chest pain

Acute New, urgent, sudden

Chronic Ongoing

Alopecia Hair loss

Cerebrovascular accident Stroke

(CVA)

Myocardial infarction Heart attack

Edema Swelling

CT scan CAT scan

Cryotherapy Freezing off

Abdomen Stomach

Tachycardia Fast heart rate, heart beating fast, heart

racing

Bradycardia Low heart rate, heart beating slow

Hyperglycemia High blood sugar

Hypoglycemia Low blood sugar

GERD Heartburn

Shortness of breath Trouble breathing

Phalanges Fingers and toes

Arrhythmia Irregular heart rhythm

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Foundational Knowledge and Basic Science: Medical Terminology

MEDICAL TERM LAY LANGUAGE

Erythrocytes Red blood cells

Vertigo Dizziness, room spinning, dizzy,

lightheaded

Syncope Fainting, temporary loss of consciousness

Deep vein thrombosis (DVT) Blood clot

Osteoarthritis Wear and tear

Amyotrophic lateral sclerosis Lou Gehrig’s disease

(ALS)

Positional and Directional Terminology

Knowledge of the medical terms that indicate directions and positions is essential for
communicating in health care. For example, for various types of examinations and
diagnostic procedures, not only must patients be positioned correctly or optimally,
those positions and how the patient tolerated them must also be documented.
The following are lists of words medical assistants can use to help understand
directional terms, as well as a list of terms that are essential for positioning.

TERM DEFINITION

Anatomical position Standard frame of reference in which the body is standing up,
face forward, arms at the sides, palms forward, and toes
pointed forward

Supine Lying face up

Prone Lying face down

Dorsal recumbent Lying facing upward with flexed knees, feet flat on floor

Fowler position Sitting upright with back angled at 90 degrees

Semi-Fowler’s position Sitting with back angled at 45 degrees

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Foundational Knowledge and Basic Science: Medical Terminology

TERM DEFINITION

Anterior Toward the front of the body, also known as ventral.

Posterior Toward the back of the body, also known as dorsal.

Superior Above; toward the head

Inferior Below; toward the feet

Medial Closer to the midline of the body

Lateral Further from the midline of the body (toward the side)

Superficial Closer to the surface of the body; more external

Deep Farther from the body’s surface; more internal

Proximal Closer to the body’s trunk

Distal Further from the body’s trunk

Dextrad Toward the right

Sinistrad Toward the left

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