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Allied Health
Assisting
Journal
Student Name:_______________________________________
School:______________________________________________
Teacher:____________________________________________
Personal Qualities of a Health Care Worker
Empathy – Identify with and understand another person’s feelings,
situation, and motives.
Honesty – Truthfulness and Integrity
Dependability – Must be prompt in reporting to work, good atten-
dance, perform assigned tasks on time and accurately
Personal Characteristics – Willingness to learn
Patience – Tolerant and understanding
Acceptance of criticism – Some will be constructive and allow you to
improve in your work
Enthusiasm – Enjoy work and display a positive attitude
Self-Motivation – Ability to determine things that need to be done
and do them without constant direction
Tact – Show consideration of the feelings of others at all times
Competence – Ability to follow instructions, know your limits, and
ask for guidance
Responsibility – Willing to be held accountable for own actions
Discretion – Understand patient’s rights and practice confidentiality
Team Player – Work well with others
Personal Appearance of a Health Care Worker
Name Tag
Clean, wrinkle free uniform, and well fitting with white or neutral
undergarments
White , clean, closed toe and heel shoes; no high heels
or sandals
Watch with second hand, note pad and pen.
No tattoos
Clean, free of body odor, and good oral hygiene
Hair up and off collar
Sport fingernails only,
NO acrylic nails, and NO nail polish
NO perfume, aftershave, or offensive odors such as
tobacco, hairsprays, and lotions.
NO jewelry or visible body piercings
NO excessive makeup, should be natural, and attractive.
The Health Insurance Portability and Accountability Act of 1996 was designed to
protect your private medical information. HIPAA established strict guidelines
for record keeping, record storage and communication in the medical and
health insurance fields. Everyone, from doctors' offices to pharmacists to those
who answer the phones at your insurance agency, has to follow the same
procedures.
PROTECTED HEALTH INFORMATION (PHI)
HIPAA's guidelines make clear exactly what information about patients is protected. Called PHI, this information includes anything that would identify a patient, from name, Social Security numbers and addresses to broader identifiers like race, age and home state. Information about the person's health care needs or medical history is also considered PHI. HIPAA guidelines dictate that this information cannot be shared except in particular instances, including when the individual patient herself requests it, or when a privacy investigation by the Department of Health and Human Services requires it.
MINIMUM NECESSARY
Arguably the cornerstone of the HIPAA guidelines is the "minimum necessary" require-ment. The health care providers and health plan administrators who have to adhere to HIPAA's guidelines must limit what personal health information -- PHI -- they share to the minimum amount necessary to accomplish the task. For example, age, race, or other demographic information might be required for a researcher to draw fair conclusions about their otherwise anonymous subjects. It would be within HIPAA guidelines to share that information, so long as the necessity could be proved and all efforts were made to protect the patient's identity.
TRAINING
HIPAA guidelines state that all professionals and other employees who come into contact with patient information must be trained in the HIPAA practices. A "privacy officer" and contact person must be designated in the workplace, and that person serves as the resource for HIPAA and patient privacy related issues. Each business that falls under HIPAA's rules must create a written set of policies and procedures that meet HIPAA requirements for record storage. Employees must have access to this information at any time. The company also must employ a system to keep track of all patient information disclosures so that their handling of sensitive medical information can be reviewed at any time.
SKILLS CHECKLIST
SKILLS DATE DATE DATE DATE DATE DATE DATE DATE DATE
Handwashing
Greeting a Patient
Filing documents in correct order
Use of proper telephone etiquette
Interpret the purpose of a visit
Scheduling procedures
Proper scheduling for office procedures
Wave Booking
Double-Booking
Modified Wave Booking
Open Booking
Stream/time-specific
Cluster or Categorization booking
Block Scheduling
Follow protocol for no-show/Cancellations
Knowledge of how to document no-show or missed appointments
Call for pre-authorization to test and procedures.
Verify Patient Billing
Provide Pt with instructions for testing and procedures
Confirming future appointments
Follow HIPPA Guidelines
SKILLS DATE DATE DATE DATE DATE DATE DATE DATE DATE
Patient Intake to confirm demographic information
Knowledge of Special needs
Verify Insurance Information
Knowledge of the Birth-day Rule
Knowledge of secondary or tertiary coverage
Knowledge of basic coding
Ensure all forms are updated and completed
Prepare encounter form
Prepare daily charts
File Medical Records
Perform Financial proce-dures, use of petty cash, creating statements/receipts
Sort and distribute mail
Follow HIPAA Guidelines
Follow OSHA Guidelines
Explain Patients’ Bill of Rights
Explain Patients insur-ance responsibilities
Explain pre and post in-structions for testing
Create correspondences
Demonstrate Computer Skills
Knowledge of Medical Terminology
SKILLS CHECKLIST
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JOURNAL NOTES/EVALUATION
DATE:___________ CLINICAL AREA:______________________________________
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Evaluation sheet for Clinical Rotations
Students Name:__________________ Date:______ Rotation Area:___________________
Comments:____________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Signature of Evaluator:______________________ Printed Name:_______________________
Area of Evaluation Check Appropriate Column
Excellent Above Average
Average Below Average
Unsatisfactory
Student in proper attire (Scrubs, white shoes, name tag,
hair pulled back, no rings, no loop earrings, facial pierc-
ing, necklaces, and bracelets)
Student exhibited good initiative (keeping busy, offering
to assist when needed, asking questions, and stays in area
assigned).
Observes Rules: Follows all regulations, Observes safety
factors
Quality of Work: Uses proper techniques, Takes pride in
work
Quality of Work: Completes tasks on time, Works effi-
ciently
Student is equipped with stethoscopes, pen, note pad, and
watch with second hand.
Student exhibits professional attitude and behavior
(courteous, attentive, good rapport with patients and staff.
Shows Ability for This Field: Readily learns procedures,
is capable & interested
Putnam County School District
ALLIED HEALTH ASSISTING
Evaluation
Student Name______________________________ Facility______________________
Date: ________ Time In: _______ Time Out: _______ Total Hours__________
Evaluation to be completed by assigned mentor:
1. Student in proper attire (scrubs, white shoes, name pin, hair pulled back, no rings, Yes___ No___
loop earrings, facial piercing, necklaces, and bracelets).
2. Student is equipped with proper items, pen, paper, journal. Yes___ No___
3. Student exhibited good initiative (keeping busy, offering to assist when needed, Yes___ No___
asking questions, and stays in area assigned).
4. Student exhibited professional attitude and behavior (courteous, attentive, good Yes___ No___
rapport with patients, and staff).
Evaluator’s comments: please note any deficiencies, positive or critical on student’s performance of skills,
attitude, and appearance, etc.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
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Evaluator’s Signature____________________________________________Date:______________
STUDENT ACTIVITY LOG: (Document any skills that were you observed performing, or any special activities that
you assisted with during clinical and explain why the procedure was done).
You may use a separate sheet of paper to attach to this page.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Student Signature___________________________________________________ Date:______________
Medical Terminology
Studies of the Body
Anatomy- study of the structure of the body and its relationship of its parts
Physiology- study of the normal functions and activities of the body
Embryology- study of the development of the body from the ovum (egg) after
the union with the male sperm
Biology- study of all forms of life
Histology- microscopic study of the structure, functions, and composition of
normal cells and tissues
Pathophysiology- study of the changes in the structures and functions of the body
caused by disease
Positions and directions Anterior - toward the front
Posterior- toward the back
Medial- near the midline
Lateral- towards the outside
Internal- inside
External- outside
Distal- away from the midline
Proximal- close to the midline
Superior- above
Inferior- below
Cranial- towards the head
Caudal- towards the tail
Adduct- move toward the midline
Abduct-move away from the midline
Anatomical Postures Erect - Standing or upright position
Supine - body flat on back, horizontal
Prone - body flat on abdomen
Lateral Recumbent - body horizontal, on either side, with knees bent
Knee Chest - on knees with head down
Movement Flexion- bending at a joint
Rotation- movement turning a body on its axis
Pronation - Turning downward
Supination - turning upward
Eversion- turning outward
Inversion - turning inward
Systems Skeletal Muscular Integumentary Gastrointestinal — Digestive
Cardiovascular Lymphatic Respiratory Endocrine Nervous Genitourinary
Medical Terminology
Relating to weights and measurements ad lib As much as desired
cc cubic centimeter
ml millimeter
dr dram
gr grain
gtt drop
kg kilogram
L liter
lb pound
mg milligram
fl fluid
fl oz fluid ounce
g gram
Relating to medications sc, sub-q subcutaneous
IM intramuscular
IV intravenous
PO By Mouth
PR Per rectum
cap capsule
Rx take
per by
sig. instruction
Relating to time NPO nothing by mouth
ac before meals
pc after meals
bid twice a day
tid three times a day
qid four times a day
q every
q lh every one hour
qod every other day
qd everyday
qhs every night
hs night or bedtime
PRN as needed
STAT at once, NOW
EDC estimated day of confinement
EXAMPLES
GET ME THE CPR CART
STAT!!
Amb bid qd
Rx: i tab bid ac
Valium 10 mg IV q 12 h
wt: 135 ht: 64 in
TPR: 98.6 72 24
Relating to Physical Examination
BP - Blood Pressure
LLL - left lower lobe (lung)
LLQ - left lower quadrant
LUL - left upper lobe
LUQ - left upper quadrant
RLL- right lower lobe (lung)
RLQ - right lower quadrant
RUL- right upper lobe
RUQ - right upper quadrant
RML - right middle lobe
os - mouth
O. S . - left eye
O.D. - right eye
O.U. - both eye
P.E., PE - Physical Examination
TPR - Temperature, Pulse, Respiration
R/O - Rule Out
c.c. - chief complaint
Dx - Diagnosis
Sx - Symptom
Relating to Medical Specialist
Pediatric- devoted to caring and curing diseases of children
Gynecology- devoted to treat the diseases of female genitourinary tract
Obstetrics- devoted to deal with pregnancy, labor and delivery
Surgery- treats diseases by operative procedures
EENT- (Eyes, Ears, Nose & Throat)- Otology-study of the disease of the ear Laryngology- study of the nose, throat, and tracheobronchial tree
Radiology- devoted to the study & treatment of the disease by means of X-ray
Nuclear Medicine- treats disease with radiation
Urology- study of the urinary system and disease
Cardiology- study of the heart and its great vessels
Thoracic Surgery- surgical treatment of the chest and its great vessels
Endocrinology- study of the endorcrine glands and their hormone secretions
Dermatology- study of the skin
Internal Medicine- treatment of diseases of the internal organs
Physical Medicine- treatment with Physical Therapy
Sports Medicine- treatment of sport injury or prevention of injury
Psychiatry- study of the mind
Geriatrics- study of the elderly
Orthopedics- study of the bones
Oncology- study of cancer
Neurology- study of the brain and nervous system
General Medicines- treatment of all ages
Emergency Medicines- treatment of person in an emergency or life threatening situation
Guidelines for Observing Patients
Senses
How well can the patient see objects close by? At a dis-
tance?
Is the patient able to hear when you speak in a normal
tone of voice?
Can the patient smell strong odor?
Can the patient sense temperature accurately?
Does the patient complain of food or beverages not tast-
ing right?
PAIN or DISCOMFORT (Remember that
pain is individualized-It does not mean the
same thing to all people.)
Where is the pain or discomfort?
How long does the pain or discomfort last?
Ask the patient to describe the pain (Sharp or dull,
throbbing or stabbing, etc.).
How does the patient rate the pain on a scale from 1
to 10, with 10 being the greatest pain?
What medication, if any, has been given to relieve
the pain or discomfort?
Has the medication helped?
Is the pain or discomfort interfering with sleep? Responses
Is the patient awake and alert?
Is the patient calm or restless?
Is the patient aware of people, place, and time?
Can the patient speak clearly?
Can the patient follow instructions?
What is the patient’s emotional state? (Does the patient appear
happy, worried, withdrawn?)
Elimination
Does the patient have difficulty urinating?
Does the patient complain of burning or soreness
when urinating?
How much urine is passed?
What color is the urine?
How often does the patient urinate?
Does the patient complain of gas?
How often does the patient have bowel movements?
Is there any bleeding with bowel movements?
Activities of Daily Living
How much personal care can the patient perform without help?
Can the patient eat without assistance?
Can the patient use the toilet, bedpan, urinal, or commode?
With what level of assistance?
Appetite
How is patient’s appetite?
How much of the food served does the patient eat (at all three
meals)?
Does the patient eat between meals?
How often does the patient drink fluids?
Does the patient complain of nausea?
Is the patient gaining or losing weight?
SKIN (Assess the skin by looking and a gentle
touch. Bath time is a good time to assess the skin.)
What color does the skin appear to be (pale, yellow-
ish, gray, flushed, etc.)?
Is the skin dry or moist?
Is the skin hot, cold, or warm?
Are there any abnormalities on the skin (rashes,
sores, bruises, etc.)?
Respiration (Assess the patient’s breathing by watching the
chest go up and down, listening to the sounds.)
What is the breathing rate?
Does the patient have difficulty breathing?
Are there any noises when the patient inhales or exhales?
If the patient has a cough, is it dry or does it produce mucus?
What is the quantity and color of the sputum?
Movement
How well does the patient walk?
Does he walk with or without assistance?
Is the patient able to move all parts of the body?
Is the patient able to get out of bed without assis-
tance? Sit up in bed?
Regions and Quadrants
NOTES
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NOTES:
Important Dates/Things to Remember:
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Career Planning
You should make a Digital Portfolio and a Notebook to keep track of important
milestones, such as awards, certifications, license, up to date shot record, and other
important documents such as a copy of your Social Security Number and birth certificate.
Begin today by going to :
WWW.FLORIDASHINES.org to set up your My Career Shines account.
Need Money for college….??
Florida Bright Futures offers just that! Stay in a program of study for at
least 3 courses, earn a GPA of a 3.5 in that program of study and overall
all GPA of a 3.0 and don’t forget to take those ACT, SAT or PERT test
early to get the scores you need prior to graduation.
Apply for FL BF Scholarships your senior year and get the community service hours
documented before you graduate from high school.
Other ways to earn money for college…..
WWW.FASTWEB.com
Apply for scholarships offered at the post-secondary institute you plan to attend.
Google is a great source for scholarships… do searches on the things you love to do in
your spare time, religion, career path, be creative!!
AND don’t wait till your Senior Year to start looking………...
How to plan your college career?
See Ms. Cauble, Career Specialist
See you Guidance Counselor
Talk to a recruiter /counselor at the college you plan to attend.
so get busy today!
Created for the CTE Allied Assisting Student
Department of Career and Technical Education
200 Reid Street
Palatka, Florida
32177
386-329-0536
The Putnam County School District prohibits any form of discrimination or harassment on the basis of race,
religion, color, sex, marital status, age, national origin, genetic identity or disability in any of its programs.
July 2017
