Medical Assistant Exam: The Basics of Professional Standards

Professionalism is a code of behavior and a set of qualities expected of the members of a profession. Medical assistants, like other professionals, are expected to live up to professional standards and a code of ethics emphasizing honesty, integrity, and service to society.

Displaying a Professional Attitude
A medical assistant is a multi-skilled professional capable of competently performing administrative and clinical tasks in a variety of outpatient or ambulatory care facilities. Characteristics of a professional medical assistant may include:
- Genuinely liking people. Ideally, the medical assistant should be a friendly, caring individual who enjoys being around people and shows a willingness to help others.
- Dependability. It is important for the medical assistant to be on time for work, to show up for work every day, and to shoulder his or her share of the work in an office.
- Flexibility. The daily schedule in a medical office often changes due to emergencies and extended appointment times. The medical assistant should be able to adjust to abrupt changes in the office environment.
- Accuracy and attention to details. The medical assistant must be able to manage details accurately in order to provide quality care to patients and to help maintain the efficient functioning of the medical practice.
- Good manners. The medical assistant should be courteous, tactful, and respectful, and should be able to represent the medical office favorably to patients and the public.
- Personal accountability for his or her actions. It is essential that the medical assistant admit to errors made or omissions that may have occurred in patient treatment.
- Membership in a professional organization. Medical assistants are encouraged to join and participate in the professional organizations that grant credentials to medical assistants—the American Association of Medical Assistants or American Medical Technologists.
- Commitment to lifelong learning. The national medical assisting organizations that grant credentials to medical assistants require continuing education to help medical assistants to keep their knowledge current.
- Professional appearance. The medical assistant should have impeccable hygiene and wear a limited amount of makeup, perfume, and jewelry. The medical assistant should dress conservatively, wearing clean, pressed clothing and comfortable, well-fitting, clean shoes.
- Positive attitude. The medical assistant should be a good team member by having a positive attitude, offering to help other team members of the team, and speaking only well about others.

Good First Impressions
As the saying goes, first impressions are made only once, and this is certainly true for the medical assistant. As the first representative of the medical facility with whom patients come into contact, the medical assistant should make a patient feel that he or she will get the best care possible. Often, a patient will judge an office by the manner in which the medical assistant answers the phone or responds to a question. All medical care—starting with the first time a patient calls the medical office—should be patient oriented, or an unsatisfied patient may seek medical treatment elsewhere.

Working as a Team to Achieve Goals
Each member of a healthcare team brings his or her individual experiences, knowledge, and expectations to the group. Group dynamics—the interacting forces among individuals in a group—are important to consider in order to become a responsible team player. These forces can include the personality of the members, the roles of team members, issues of power and control, and even friendships among the various team members.
A new medical assistant may feel intimidated by certain aspects of the group dynamics in his or her office. For instance, more experienced medical assistants or other healthcare personnel on the team may cause a new medical assistant to feel less important, and extroverts may be more vocal and overshadow the opinions of more introverted team members. All group issues must be recognized and individually dealt with in order for the healthcare team to fully understand the dynamics of the group and to come together when caring for patients. The team leader should focus the efforts of the team toward a common goal and should encourage communication between team members.

Communication
Communication is the exchange of information, both verbally and nonverbally. Oral communication relies on the spoken word and the tone and inflections of the voice. Communicating effectively with patients and their families is an essential skill needed by the medical assistant.

Four key attributes define professional communication and behavior.
- Tact is having a good sense of how to avoid offending or insulting an individual or being sensitive and considerate when choosing to discuss issues with patients or coworkers. The tone in which something is spoken is as important as the words used.
- Diplomacy allows the medical assistant to handle delicate situations between groups or individuals without arousing hostilities.
- Courtesy refers to treating individuals in a thoughtful and respectful manner, and is critical for all people the medical assistant comes into contact with (patients, physicians, and coworkers).
- Responsibility and integrity are also important traits for medical assistants. These traits increase patients’ trust and create camaraderie among all the individuals in a healthcare team.

Verbal (spoken words) and nonverbal (gestures and facial expressions) communication are closely linked. The medical assistant is trained to be a good communicator, actively listening to the patient and asking various types of questions to elicit information or clarify the message from the patient, and providing feedback to the patient (that is, a response to his or her question, comment, or concern).
How skilled a medical assistant is at interviewing patients also plays a role in the information received verbally from a patient. A skilled medical assistant may realize that the nonverbal message the patient is communicating is not the same as the words being spoken.

Nonverbal Communication
Nonverbal communication is the exchange of information without exchanging words. Nonverbal communication is made up of body gestures and poses and is often referred to as body language.
The study of body language is called kinesics. According to Alton Barbour, author of Louder Than Words: Nonverbal Communication, the total impact of a message breaks down as follows: 7% verbal (words), 38% vocal (volume, pitch, rhythm), and 55% body movements (mostly facial expressions). Clearly, nonverbal communication plays an important role in a patient-healthcare team relationship. Observing a patient’s nonverbal messages is just as important as hearing the words he or she is saying. The medical assistant should also be aware of his or her own body gestures, as well as the messages those gestures may be sending to patients or coworkers.

Listening Skills
Listening skills should be used by the medical assistant in all area of conversations with patients and coworkers. Nonverbal messages are sent even when someone is just listening to a conversation. Glancing away from the speaker, looking at the clock on the wall, or placing one’s hand on the doorknob of the examining room’s exit may indicate impatience or lack of interest in what is being discussed.

Eye Contact
Eye contact is a means of nonverbal communication that can strongly reinforce the spoken word. Eye contact can send a message of honesty and confidence. Some people may feel a person is not telling the truth if he or she is having trouble keeping eye contact. Others may believe that avoiding eye contact shows that a person is shy or nervous. However, most people agree that it is rude to stare at someone.

Adapting Communication to an Individual’s Needs
Speech, hand signals, writing, behaviors, body gestures, and tone of speech are a few examples of the many ways humans communicate. The medical assistant must have a basic understanding of these various communication tools and be aware of the need for adapting communication according to an individual’s needs.

Roadblocks to communication may include a variety of physiological, emotional, or psychological impairments; cultural differences; age-related difficulties; or language barriers. The medical team should be prepared to adapt communication to meet address these roadblocks. Individuals who may need some type of adjustment in communication include:
- The visually impaired. The medical assistant should ask before assuming that a visually impaired person needs help. Also, the patient should be informed when the medical assistant is leaving the room. Braille signs should be available on doorways and on elevator control panels.
- The hearing impaired. When communicating with a patient with a hearing impairment, the medical assistant should face the person directly because some hearing impaired people read lips, and facing the patient directly helps his or her comprehension. Writing down instructions is another way to communicate effectively with a hearing-impaired patient.
- The elderly. An elderly patient’s ability to see, hear, and respond coherently should be assessed by the medical assistant before automatically assuming the patient has a physical or psychological impairment. However, some elderly patients may be a little slower to comprehend or to remember details of instructions, so the medical assistant should state instructions in a clear, concise manner, eliminating extra steps and unnecessary details. Elderly patients should be addressed in a respectful manner, not with terms such as 'Gramps' or 'honey.'
- Children. Children should be treated with the same respect as adults. Children experience the same fears and apprehension that adults feel when going to a medical facility. The medical assistant must gain the confidence of the child in order to establish a positive relationship. Also, it is important to be honest with the child. For example, a child should not be told that an injection won’t hurt. The medical assistant should reassure the child that it will hurt for only a moment and provide comfort immediately after the injection.
- Seriously ill patients. Seriously ill patients and their family members are suffering and may need someone to listen to their concerns. The medical assistant should allow these patients to express their feelings, and provide comfort and solutions to their problems when possible. The medical assistant should also encourage a patient to speak with a psychologist or mental health professional who has been trained to deal with problems beyond the expertise of the medical assistant and the rest of the staff in the medical office.
- The mentally impaired. Respect and patience are needed for communicating with mentally challenged individuals. The medical assistant should speak directly to the individual, observing facial expressions that would indicate the level of comprehension. Using simple terms and repeating explanations can help mentally impaired patients feel involved in their own care.
- Illiterate patients. If a patient is illiterate, verbal explanations and directions may be used. An illiterate patient may have difficulty taking prescription medication properly or remembering detailed instructions. If it is agreeable to the patient, a family member may be asked to read any written instructions given to the patient.
- Non-English-speaking patients. The medical assistant may have to communicate with patients who do not speak English or who speak very limited English. The medical assistant should try to communicate with these patients as effectively as is possible. For instance, it is often possible to communicate greetings, directions, or simple instructions through nonverbal communication.
- Anxious patients. An anxious patient may have difficulty understanding or remembering verbal instructions or information because his or her thoughts are focused on other issues. The medical assistant can help relieve a patient’s anxiety by being friendly and calm and by encouraging the patient to discuss the issues or concerns that are causing the anxiety.
- Angry or distraught patients. When an angry or distraught patient calls the office, the first thing the medical assistant should do is listen. Listening closely to what the patient is saying can help identify the problem and help the medical assistant to work with the patient toward a solution.
- Culturally diverse patients. A medical practice may have many culturally diverse patients, people from various ethnic, racial, and socioeconomic groups. The personnel of a medical facility may also be culturally diverse. Individuals from different cultures may have established value systems that do not match the value systems of the medical assistant. The medical assistant who has some knowledge of cultural customs may be able to prevent misunderstandings with patients or coworkers that are a result of cultural differences.

Handling Emotional Barriers in Pre-Op Patients
Emotional barriers might arise when the medical assistant is trying to discuss pre-op instructions with a patient. The patient may not be able to absorb what is being said because he or she is so worried about the danger of the surgery or about how to find the money to pay out-of-pocket expenses.
The medical assistant should ask the patient about his or her major concerns about the surgery prior to discussing the pre-op directions. The medical assistant should also offer to discuss a payment plan with the accounting office or to set up a time for the patient to discuss his or her concerns about the dangers of the surgery with the physician. These actions may help remove the emotional barrier and allow the patient to concentrate on the important information relayed by the medical assistant.

Barriers to Communication
Barriers to communication can be physical, emotional, or psychological.
- Physical barriers to communication may include visual, auditory, or speech impairment. Physical barriers to communication may also apply to the workplace itself. Closed office doors, barrier screens within the office, environmental noise, and even a glass partition between the reception area and the front office where the medical assistant sits can all create obstacles to communication.
- Emotional barriers that hinder open and free communication often stem from fear, mistrust, and suspicion. As children, we are often taught to keep our feelings to ourselves. Emotional barriers may also consist of fear, mistrust, or suspicions. The medical assistant should be able to identify the emotional needs of others and be aware of emotional barriers that may interfere with patients’ listening and understanding.
- Psychological barriers are closely related to emotional barriers and may include fear of losing independence, fear of the stigma attached to certain conditions or diseases, or fear of not wanting be dependent on others. Psychological and emotional barriers may prevent a patient from seeking medical attention. Patients under stress may see situations differently than they would if they were not under stress. When a patient is under stress, he or she may blow a small issue out of proportion. For example, the patient may have less patience about waiting for an appointment or for a lab result than he or she normally would.

Techniques for Active Listening
When actively listening, the medical assistant should spend more time listening than talking, giving the patient 100 percent of his or her attention. The medical assistant should show that he or she is listening by looking directly at the patient and acknowledging that he or she understands what the patient is saying. The medical assistant should allow the patient to finish speaking before interjecting any opinions, and provide feedback by asking questions to clarify the patient’s message. The medical assistant should also be aware of his or her body language.

Cultural Factors in Communications
A person’s cultural background may influence how he or she interprets a situation. Perception, or how another individual sees a situation or an individual, is often based on past experiences, biases, and stereotyping.
- A bias is a predetermined slant or attitude about a person or situation that may interfere with one’s impartial judgment—for example, the belief that male patients should be treated only by male physicians or that female patients should be treated only by female physicians.
- Prejudice also involves making predetermined conclusions or judgments without knowledge, thought, or reason. A prejudice may be expressed as a negative comment against a group of individuals based on their culture, religion, or nationality.
- A stereotype is a generalized assumption about a group of individuals that can be either positive or negative. For example, it would be a stereotype to say that all elderly patients are hearing impaired or to say that all teenagers take illegal drugs. It would also be a stereotype to say that girls are smarter than boys. Medical assistants must be able to identify their own personal biases and prejudices so that they can avoid stereotyping patients and coworkers.

Maintaining a Therapeutic Relationship
The term therapeutic relationship refers to the relationship that the medical assistant and other members of the healthcare staff have with a patient. In a positive therapeutic relationship, the patient is made to feel accepted and respected. Some factors in developing positive therapeutic relationships with patients are:
- treating all patients impartially by avoiding prejudice, bias, and stereotypes
- having an understanding of emotional behavior—such as stress, anger, and fear—during times of stress and illness
- having and expressing empathy for the patient and his or her circumstances. Empathy is putting yourself into someone else’s shoes, understanding how an individual feels while keeping the focus on that person. Sympathy involves a more emotional response and may result in a lack of objectivity on the part of the medical assistant.

Patient Interviewing Techniques
Different questioning techniques can be used to gather information needed from a patient. Questions should be exploratory in nature, geared toward eliciting information about the patient’s understanding his or her condition, of the treatment, and of the patient’s feelings about them. Exploratory questions, or open-ended questions, require the patient to answer in more than one word, encouraging the patient to provide information. Asking a patient a closed question will often result in a yes-or-no answer, limiting the response and information received. For example, if the medical assistant asks the patient, 'Are you following your low-sodium diet, Mr. Smith?' he could simply answer, 'Yes' or 'No.' If the medical assistant asks the question in an open-ended way, such as, 'Mr. Smith, what foods you are eating on your low-sodium diet?' the patient will likely respond with more detail.

Evaluating the Effectiveness of Communication
Evaluating the effectiveness of their communication with patients, and adjusting their techniques accordingly during conversations, are important to medical assistants’ communication with patients. The communication process involves a sender, the person sending the message; a receiver, the person receiving the message; and a message, the content or information being transferred.
Channels are part of the communication process and include various types of verbal and nonverbal methods, such as speaking, writing, and body language, to convey messages. More than one channel may be used to send information and to help clarify the message being sent.
Feedback, the final part of the communication process, is the response given to the sender of the message. Feedback allows the sender to evaluate whether the receiver correctly understood the message sent. Feedback also gives the sender an opportunity to correct any misunderstandings in the message. For example, the medical assistant may respond to a worried-looking patient’s statement 'I can’t wait to get this operation over with' by rephrasing the statement as 'You seem to be nervous about the surgery. Is that right?' Being aware of the patient’s concern, the medical assistant may ask more questions to find out the patient’s exact fears, answer any questions the patient may have, or refer the patient to the correct person.

CEUs
The medical assistant has the responsibility to keep his or her credentials current. Continuing education units, or CEUs, may be obtained by taking continuing education courses, attending approved lectures and conferences, and reading approved articles in magazines such as CMA Today. Often, reimbursement for continuing education courses and conferences may be available from the employer. The medical assistant must accurately keep track of earned CEUs in order to be sure that the appropriate number and types of credits earned will be applied to the recertification of the credential.

Active Listening
Active listening is more than just hearing another person talk. When a medical assistant actively listens to a patient, he or she is interpreting the message being sent and paying close attention to the words used in the conversation as well as the tone of the words spoken.

Legal Restrictions
When interviewing patients, the medical assistant must remember that the patient’s medical record is confidential. Before the patient interview begins, the medical assistant should inquire if the patient has any questions. Balancing the need-to-know details of a patient’s condition and history with respect for the patient’s privacy is one of the challenges of the patient interview.
Medical history is the basis for all patient care; therefore, it needs to be detailed and complete. The medical assistant must be sensitive to the feelings of the patient when he or she is asking the patient personal questions. Often, if a patient is initially reluctant to answer a question, the medical assistant may readdress the topic later in the interview, when the patient is more relaxed.
Accurate documentation during a patient interview is also important because the medical record is a legal document. There are no legal restrictions on questions asked during a patient interview, as long as the questions relate to or are necessary for the patient’s medical problem or care.
Care must be taken to ask questions about sensitive topics such as sexual activity or drug or alcohol use in a matter-of-fact tone and to accept answers in a nonjudgmental manner. The patient should be reassured that all conversations will remain confidential.

Medicolegal Guidelines and Requirements
In a medical office, established guidelines govern the physician-patient relationship. The patient has the right to expect quality care, confidentiality of personal information, respectful treatment, and the right to make his or her own healthcare decisions. The physician and medical staff members have the right to protect themselves against lawsuits.
Medical assistants must be aware of current federal and state laws regulating many issues in a medical facility. Failure to be compliant with federal regulations and standards may lead to legal actions against the medical facility and against the medical assistant.

Medical Practice Acts
The Medical Practice Acts are statutes, or laws designed to protect patients from harm. Each state has its own set of regulations that oversee the licensing of physicians, the physician-patient relationship, standards of care, professional liability (malpractice), rules of confidentiality, and professional behavior and record management.
The medical assistant in a medical facility is under the direct supervision of the physician and acts on the physician’s behalf when performing many procedures and clerical tasks and, therefore, may be held responsible for failure to comply with state and federal regulations or failure to act within the scope of medical assisting education and training.

Tort Law
Failure to comply with the provisions of the Medical Practice Acts may result in committing a tort. A tort is a wrongful act, other than a breach of contract, which results in the injury of another person, who may seek compensation for damages that may have occurred as a result of the act. A tort falls under civil law, and the penalties for committing a tort can range from monetary fines to imprisonment, depending on the violation.
A common tort at issue in medical practice is negligence, which implies low standards or poor conduct. Negligence indicates a failure to exercise care and treatment that correspond to reasonable professional standards.
A medical assistant may be charged with breach of duty if he or she performed with low standards or poor conduct and if the patient or his or her family feel that the medical assistant provided a poor standard of care that resulted in physical or emotional harm to the patient. Even though the medical assistant is under the supervision of a physician, the medical assistant is responsible for adhering to a standard of conduct established by medical assistant professional organizations.

Licenses and Certifications
Most professions have some type of regulation to ensure the competency of their members. Professionals may be licensed, certified, or registered.

The Licensing of Physicians
Physicians must be licensed in the state in which they are practicing. Qualifications to take the licensing exam for physicians include graduating from an approved medical school, completing an approved residency program, and reaching the age of majority (the legal age of adulthood).
Once licensed, a physician may choose to work in another state and obtain a license for that state through the process of reciprocity rather than taking the licensing exam for the second state. Reciprocity is the mutual exchange of privileges between states, meaning that if a physician holds a license in one state and has equal or higher qualifications than those required by the state in which they are applying, that state will grant a license without requiring the physician to take that state’s licensing exam.

Revocation and Suspension of a Physician’s License
A physician’s license must be renewed every two years. In every state, physicians must also complete an annual five-hour training session for risk management and show proof that continuing education has been done. It is illegal to practice medicine without a valid license. The law does not differentiate between a person who practices with a lapsed license and a person who never qualified for a license.
The physician who does not comply with federal and state regulations may be fined or charged with a felony, which is a serious crime usually punishable by prison time. A physician may also have his or her medical license revoked if convicted of a crime.
Fraud is an intentional deception usually made for personal gain, such as billing for procedures and services never performed or falsifying medical records. Fraud is considered less serious than a felony and may be considered a misdemeanor, depending on the crime committed.

A physician may have his or her medical license revoked because of unprofessional conduct such as:
- substance abuse—addiction to legal or illegal drugs or alcohol
- impersonating another physician or falsifying credentials
- providing substandard care—practicing medicine in a manner that harms or may harm a patient
- prescribing controlled substances for reasons other than the accepted therapeutic purposes
- inappropriate billing practices

Certification and Registration for the Medical Assistant
Certification and registration are voluntary for the medical assistant. The medical assistant may earn either a CMA or an RMA certification after completing the national exam offered by one of the two national accrediting agencies for medical assisting. Credentialing is important for the graduate of a medical assistant program; many medical facility employers prefer to hire certified or registered medical assistants because certification demonstrates competency in the medical assisting areas. To remain certified or registered, the medical assistant must complete continuing education units (CEUs) as required by the national organizations. (See Chapter 1, 'The Medical Assistant Profession,' for more information on certification and registration.)

Legislation
Various legislation has been passed to cover medical-legal issues that have arisen over the years as a result of breakthroughs in technology, advancements in patient care, and the desire to make the patient an active decision-maker in his or her medical care. The information that comes to a medical office from many different sources provides data regarding tax regulations, updates to controlled substances, or even changes in employment laws. The medical assistant has the responsibility to be aware of these federal and state regulations.

Advance Directives
Advance directives are legal directions that provide an individual with a way to communicate his or her decisions about end-of-life care to family, physicians, and healthcare professionals. Specifically, an advance directive is a document signed by the patient that outlines what types of treatments that patient authorizes in the event that he or she becomes incapacitated or unable to make decisions. When the patient spells out and legally documents his or her decisions, there is no confusion as to what the patient wants.
- A living will is a limited type of advance directive: It covers only the decisions an individual has made about life-sustaining procedures in the event that death is imminent or that the individual is in a permanent vegetative state with no hope of recovery. An advance directive is more encompassing than a living will. For instance, it allows an individual to select a healthcare agent to make healthcare decisions if and when the individual cannot make the necessary decisions.
- A durable power of attorney for healthcare is a document that names the person a patient has chosen to represent him- or herself. This selected person, called a healthcare agent, will be responsible to make the final decisions about the individual’s end-of-life healthcare. The chosen person should be a trusted family member, friend, or attorney.

An advance directive does not have to be prepared by a lawyer, but the individual should get some information about the types of life-sustaining treatments that are available and may be used in his or her care. For example, the patient must decide if he or she is willing to be put on a dialysis machine or a respirator, if CPR should be administered if the heart or breathing stops, or if a feeding tube may be inserted. Decisions about organ donation should also be considered.
The medical assistant should place a copy of any advance directives in the individual’s medical file for safekeeping, making sure that it exists in a prominent place in the patient’s records. A copy of the advance directives should be given to the healthcare agent of the individual.
Each state has its own guidelines for advance directives. Once the advance directive is prepared its signing must be witnessed by two adults. Although state laws vary, it is recommended that at least one witness be someone who is not affiliated with the individual’s healthcare facility and the other witness be a physician.

Anatomical Gifts
The Uniform Anatomical Gift Act governs the making of anatomical gifts after death (and sometimes before death) for either organ donation for transplants or cadaver donation to medical schools to be used for educational purposes. An individual must be at least 18 years of age to complete an organ donation form, although the law allows a surviving spouse or relative to make an organ donation decision upon the death of an individual. Tissue, cells, and body fluids may be used for donation and may include some of the following: kidney, lung, pancreas, liver, skin, intestines, stomach, testis, hand, cornea, blood vessels, bone, blood transfusions, islets of Langerhans, or heart.
Some organs may not be suitable for donation if the patient had certain infectious diseases or some types of cancer. The medical team in charge of the transplant will make the final decision of whether an organ is acceptable for transplant. There is no specific age limit for organ donation. Many sources state that donations may be accepted from newborns to about age 70 for cadaver organ donations. Tissue and cornea donations may come from older individuals (up to 80 years old), and there is no cutoff age for skin donation. When an individual decides to become an organ donor, he or she can donate as many organs or as few organs as desired. There is no charge to an organ donor or his or her family.

Reportable Incidences
Reportable incidences may include communicable diseases, substance abuse, chemical dependencies, wounds resulting from violence, and certain statistical information such as births and deaths. Reporting allows for the gathering of important statistics regarding how often specific diseases or conditions occur. These statistics give researchers the ability to identify trends, including any increase or decrease in disease outbreaks, with the hope of controlling future outbreaks. Statistics gathered about chemical dependencies and substance abuse can also be used to research treatment and prevention areas.

Birth and Death Data
Reporting of births and deaths to the State Center for Health Statistics is important in compiling infant mortality rates based on the infant’s birth weight, mother’s age, prenatal care, smoking and alcohol use during pregnancy, mother’s education, and any other area deemed important to measure. In many states, details about stillbirths are reportable. Information gained from analyzing these statistics may be helpful in identifying risk areas for fetuses and newborns, which may then be prevented through education.
Statistics gathered from adult mortality rates provide insight into the types of diseases and conditions causing deaths in the United States. This statistical information may be used to report on the progress of curing or managing diseases (thus prolonging life), such as early cancer detection and the identification or treatment of diseases and conditions that are increasing (e.g., diabetes and obesity).

Communicable Diseases
Communicable diseases are classified as infectious diseases that may be transmitted from one individual to another. It is the responsibility of the healthcare provider to report the diseases to the state or local health agencies.
Acts of violence such as stabbings, gunshot wounds, and poisoning—whether accidental, suspicious, or unexplained—need to be reported to the local police department. Statistics from violence reporting can provide information used for prevention and education, in the hopes of decreasing violent activity or injury.

Occupational Safety and Health Act
The Occupational Safety and Health Act (OSHA) was legislation passed in 1971 to ensure employee safety and health in the working environment. The goal of OSHA was to make working environments safer and healthier by employing fair and effective enforcement of its regulations, setting safety and health standards, establishing training and education for employers and employees, and providing compliance assistance to worksites.
OSHA safety regulations include standards to regulate noise and exposure to hazardous substances such as lead, toxic chemicals, asbestos, and pesticides. Workplace safety issues addressed by OSHA of specific concern to medical facilities are discussed in Chapter 5, in the 'Infection Control' section.

Food and Drug Administration
The Food and Drug Administration (FDA) is an agency within the U.S. Public Health Service, which is a part of the Department of Health and Human Services. The Food and Drug Administration was created when Congress passed the Pure Food and Drug Act of 1906, the first in a series of acts designed to regulate foods and patent medicines. The Pure Food and Drug Act requires that all drugs marketed in the United States meet minimal standards for purity, strength, and quality. The act requires that any drug containing morphine be labeled appropriately and identify the ingredients. The Pure Food and Drug act also established two references that listed officially approved drugs—the United States Pharmacopeia (USP) and the National Formulary (NF), which are now combined into one reference book.
Enacted over time, federal legislation established stricter and more specific guidelines that prevented tampering with drugs, required accurate labels and warning labels for side effects such as drowsiness on certain products, and designated which drugs need a prescription and which can be sold over the counter without a physician’s prescription.

Controlled Substances Act of 1970
The Controlled Substances Act of 1970 put a tighter control on the substances being abused by the public, such as narcotics, depressants, stimulants, anabolic steroids, and psychedelic drugs. This act isolates abused and addicting drugs into five schedules, or categories, indicating the potential for abuse and addiction. The higher the schedule number, the lower the potential for addiction and abuse. For example, Schedule I includes drugs that have the potential to be highly addictive and abused and that have no medicinal use, such as heroin; the drugs on Schedule V have the least or lowest potential for addiction and abuse, such as cough suppressants containing codeine.
The legislation sets strict security rules for anyone who dispenses, receives, sells, or destroys any of the controlled substances (drugs) listed in the five schedules. Physicians, pharmacists, hospitals, and drug companies fall into that category. The controlled substances are to be kept under double lock and key, and an exact inventory of each substance is to be kept with documentation of every dose dispensed. Inventory lists must be on file for two years. Any outdated or contaminated drug (those dropped on the floor, for example) must be returned to the pharmacy rather than discarded.
Limits are set on the number of prescription refills that are allowed in a six-month period, and dictate whether a specific controlled substance can be prescribed by phone to a pharmacy or whether the drug requires a written prescription. Some states may have stricter schedules than those set by the federal government. The act requires that each prescriber be registered with the Drug Enforcement Administration (DEA), a bureau of the Justice Department that was set up to enforce the provisions of the Controlled Substances Act. Each prescriber applies for and receives a registration number that has to be written on all prescriptions for controlled substances. The registration needs to be renewed every three years. The medical assistant may be responsible for the renewal of the physician’s DEA registration number.
Keeping prescription pads out of sight and unavailable to patients and keeping all drugs safely locked away during and after office hours help to prevent unauthorized access to controlled substances. The drugs are kept under double lock and key; the medical assistant should be aware of the location of the key at all times.

Clinical Laboratory Improvement Act of 1988
The Clinical Laboratory Improvement Act (CLIA) of 1988 was passed by Congress to develop quality, comprehensive standards that would ensure the accuracy of laboratory testing in facilities that process human specimens for the purpose of diagnosis, prevention, and treatment of diseases. The goal of the standards is also to improve reliability and to decrease waiting times for test results, regardless of where the test is performed. In 1992, CLIA regulations were recategorized based on the complexity of the test method, with more stringent regulations being required for more complex tests. Laboratory tests are now divided into three categories: waived complexity, moderate complexity, and high complexity. Specific standards have been set for each level of testing category.
CLIA regulates laboratories in order to be sure that the standards are being met. A comprehensive quality assurance program for a laboratory is designed to analyze every aspect of the testing—from collection of the specimen to the final determination of the test results. The overall quality of the total testing process is evaluated. If an error is discovered in any part of the testing, then sequence corrective measures are instituted so that the goal of quality is achieved.

Americans with Disabilities Act
The Americans with Disabilities Act (ADA), established in 1991, protects the rights of people with physical and mental disabilities. This law applies to business that have 15 or more employees. Medical offices must comply with specific guidelines for easy accessibility to the medical facility for those with disabilities. 

Health Insurance Portability and Accountability Act
Enacted by Congress in 1996, HIPAA aims to improve the efficiency of the healthcare system. The main areas addressed by HIPAA regulations include:
- providing protection of healthcare coverage for workers and their families when they change or lose their jobs
- improving access to long-term care services and coverage
- simplifying the administration of health insurance
- promoting the use of medical savings accounts
- prohibiting discrimination against employees and their dependents based on health status
- guaranteeing renewal of health coverage
- providing security and privacy of health data

Regulations limit access to the medical records of patients. Insurance companies that pay for patient services through health plans; physicians, hospitals, nursing homes, pharmacists, and chiropractors who treat patients; and healthcare clearing houses that process insurance claims are among the healthcare entities allowed access to private patient information.
Not all organizations or agencies are required to follow the rules set by HIPAA. Carriers for life insurance and workers’ compensation, state agencies such as child protective services, many law enforcement agencies, school districts, and employers are not governed by the HIPAA regulations. An employee personnel record, for instance, is not considered confidential even if it contains health-related issues. Because an employer is not regulated under the privacy rule, the employer has the right to ask an employee for a doctor’s note to determine whether an employee may return to work or to determine an employee’s status under a worker’s compensation claim. The employer does not have the right to ask the physician for the note, and the physician has the right to deny the employer access to any of the patient’s medical information without the patient’s written permission, unless required to do so by law.

Drug Enforcement Administration
The Drug Enforcement Administration (DEA) is a bureau of the Justice Department that was set up to enforce the provisions of the Controlled Substances Act. The DEA is the lead agency for domestic enforcement of drug policy in the United States (sharing concurrent jurisdiction with the FBI) and is the sole agency responsible for pursuing U.S. drug investigations abroad. Prescribers of drugs are required to be registered with the DEA. Information on the registration process is included in this chapter in the 'Controlled Substances Act of 1970' section (page 64).

Internal Revenue Service
The W-2 and the W-4 are two forms issued and reviewed by the Internal Revenue Service (IRS) to determine the taxes due from individual workers. Both forms deal with employee wages but are used for different purposes.
The W-4 form contains identifying information about the employee such as his or her name, address, and social security number. The W-4 form allows the employee to report to the employer the number of allowances to be used in calculating payroll deductions for the employee. 
The W-2 form is the document used by the employer to report the wages for a specific employee for the year and is filed once a year, usually by the end of January. The W-2 form contains identifying information about the employee and the employer. It also breaks down the wages and payroll deductions applied to the employee’s past year of wages and withholdings. The employer is responsible for filing the W-2 to the IRS and the state taxing authority and for providing the employee with multiple copies to include with his or her income tax returns.

Equal Employment Opportunity Laws
The Federal Equal Employment Opportunity (EEO) laws prohibit discrimination against individuals seeking employment. Discrimination in the workplace means treating individuals differently based on factors other than individual merit and may include areas such as hiring and firing, compensation for work, promotions, recruiting, fringe benefits, and retirement plans. Discriminatory practices may include harassment, retaliation if complaints are made about discrimination, and denying employment opportunities based on age and gender. The federal Equal Employment Opportunity laws include the following acts:
- Title VII of the Civil Rights Act of 1964 prohibits discrimination for employment based on race, religion, gender, or national origin.
- The Equal Pay Act (EPA) of 1963 prohibits gender-based discrimination within a specific place of employment by requiring equal pay for equal work regardless of whether the employee is male or female.
- The Age Discrimination in Employment Act of 1967 (ADEA) prohibits discrimination against individuals age 40 and over. It is illegal to refuse to hire an individual based solely on his or her age. This discrimination law applies to all employers with 20 or more employees and includes both state and federal agencies.
- The Rehabilitation Act of 1973 prohibits discrimination against qualified employees with disabilities who are employed in the federal government.
- The Americans with Disabilities Act of 1990 prohibits employment discrimination against qualified applicants because of disabilities.
- The Civil Rights Act of 1991 provides compensation (which may be monetary) to individual victims of intentional employment discrimination.
- The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits discrimination against applicants or employees based on genetic information. (Genetic information may consist of an individual’s genetic test results and information about any genetic diseases or conditions that may predispose this individual to a higher risk for getting a disease or condition in the future, such as an individual’s risk for certain types of cancer.)

Workers’ Compensation
Workers’ compensation laws protect employees who are injured or disabled on the job or due to work performed. An individual may be entitled to recover medical fees, lost wages, and future wages depending on the severity of the injury. Workers’ compensation laws include both state and federal laws (although federal compensation laws deal mainly with federal employees). In most states, employers are responsible for purchasing a workers’ compensation insurance plan to cover injuries that occur on the job. Covered injuries do not necessarily have to be caused by a one-time accident (such as a burn or a laceration from a broken bottle). The injuries may occur gradually over time from repetitious behaviors—for example, a lung condition caused by exposure to toxic chemicals over time.
Certain conditions may prevent workers’ compensation from covering an injury received at work. If the injury occurred from a violation of posted and known rules, workers’ compensation would not cover the incident. For instance, if an individual did not wear the required personal protective equipment for a particular procedure, or if the injury occurred because the individual was intoxicated or using drugs that impaired his or her judgment, then coverage would not be available. Preexisting conditions may also be excluded from coverage, unless it can be proved that the current working environment exacerbated the symptoms.

Medical Records
Documentation of procedures, treatments, and care provided to patients is an essential function of the medical assistant. HIPAA regulations of patient privacy govern who has access to the documentation concerning patients.
Documentation in the medical record needs to be accurate, legible, and correct because the medical record is considered a legal document and may need to be used in a court of law. Proper procedure must be used when making a correction to a medical record. (For information about the proper procedure for correcting the medical record, see Chapter 4, 'Administrative Procedures: Medical Records Management: Making Corrections to Medical Records.') Written patient consent is needed when information is to be reported, transferred, or released.

Personnel Records
Personnel records are usually kept so that the medical office has organized information about each employee available, if needed. Much of the information in the personnel record is required by federal and state government agencies for tax information.
Many states regulate who may have access to an employee’s personnel record. All states seem to agree that an employee has the right to examine the contents of his or her own personnel record and may request copies of the information in the record; however, in some states the employer does not necessarily have to comply with the employee’s request. Most states agree that the employer owns the personnel record and the contents within the record. Personnel records should be correct, and if an employee has the option to review his or her personnel record and finds an error or disagrees with its content, a written response by the employee may be included in the record stating the employee’s version of the recorded situation.
Access to the personnel record should be limited to only those in the company who may need the information. Personnel records should be kept in a locked cabinet; employee authorization is needed before information can be sent or released to others inquiring about the employee.
The Personnel Record Review Act of 1990, used by some states to oversee the proper use of personnel records, dictates that employers cannot keep a record of an employee’s activities, such as political activities or organizational membership, occurring off the premises of the place of employment. Although the law states that keeping personnel records is not mandatory, keeping information regarding job performance and work-related issues in the personnel record may be beneficial to the employer if, for instance, a disgruntled employee decides to sue for wrongful termination. The personnel record will help in the employer’s defense.

Tickler Files
Tickler files are useful for keeping track of patient information such as lab test results or reminders to notify patients about appointments or other scheduled activities. An efficient tickler system may also be used to keep track of renewing important information. For example, the physician’s licenses for practicing medicine, his or her license to prescribe controlled substances, and his or her malpractice insurance should not be allowed to lapse. A tickler system may help the busy medical assistant remember these important dates.

Performance Evaluations
Performance evaluations are regularly scheduled reviews of how well an employee is performing at his or her job. Performance evaluations provide the employee with a chance to learn what the employer feels his or her strengths are and what areas need improvement. Traits evaluated may include flexibility, dependability, and ability to work well with coworkers on the team.
The employee’s performance evaluation is also a time when the employee can discuss issues of concern about the job. Many performance evaluations now include questions about the employees’ goals for the future and accomplishments made during the year.
Although not all medical offices use a rigorous written evaluation policy, it is the best way to keep a record of employee evaluations. The written evaluation is presented to the employee, who has the right to make comments (whether oral or written) about the evaluation. The evaluation is then signed by both the employee and the employer and kept in the personnel record of the employee.

Consent
Three kinds of consent are possible in the course of a patient’s medical care.
- Implied consent is an indirect acceptance, for example, when a patient may extend his or her arm for the medical assistant to measure the patient’s blood pressure.
- Expressed consent is a spoken or written agreement that provides consent. Many times a nonverbal gesture such as a handshake is considered expressed consent.
- Informed consent is a written statement signed by the patient, agreeing to the procedure or treatment recommended by the physician only after receiving a detailed explanation of the procedure to be done, the reasons for the procedure, the risks involved, complications that may occur, and any alternate methods of treatment that may be used instead of the procedure being discussed. Many times a patient may be asked to write a description of what the procedure entails in his or her own words to be sure that there is a clear understanding of what will be done. A physician who fails to obtain informed consent from a patient may be charged with the crime of battery. Patients may also be asked to sign a written consent or a written authorization in order to release information to a third-party payer, such as an insurance carrier, for reimbursement procedures.

Scope of Practice
Medical assistants are bound by law and ethics to perform only procedures and skills within their scope of practice. Scope of practice is the general term used to describe the procedures and tasks that a professional medical assistant can and cannot do. Scope of practice is limited by state laws, education and training, and level of experience. Because state laws vary, the medical assistant is responsible for knowing which skills may be performed in the state in which he or she practices.
Medical assistants should never diagnose a patient’s condition or make independent medical assessments. Medical assistants should give medication only under the direct supervision of a physician (and only in states in which administration of medications by a medical assistant is allowed). Also, some state laws require special training and licensing to perform phlebotomy, take X-rays, or do an ultrasound.
The medical facility should clearly list its policies regarding which procedures are acceptable for a medical assistant to perform. Acting beyond the scope of practice can expose the medical assistant and the medical assistant’s supervisor to a lawsuit.

Releasing Medical Information
Rules and laws (such as HIPAA) have been established to protect patients’ privacy and limit access to medical records of patients. The only individuals or entities allowed access to patients’ information are:
- insurance companies that pay for patient services through health plans
- healthcare providers such as physicians, hospitals, nursing homes, pharmacists, and chiropractors who treat patients
- healthcare clearinghouses that process insurance claims

Even for these individuals or entities, certain conditions must be met in order to gain access to patient information. In some instances, written consent is required. Other parties, such as patients’ friends and families or patients’ attorneys, nearly always need patients’ written consent before they may have access to patient information.
HIPAA requires medical facilities to identify in writing the policies regarding patient confidentiality and the release of patient information. The medical assistant has the responsibility to maintain the patient’s confidentiality in all areas of patient care. Care must be taken so that private patient information is released only with the written permission of the patient, or as otherwise required by law.

The Medical Assistant and Confidentiality
The medical assistant must be careful not to repeat any information about a patient that may be overheard by others. Test results should not be left in a voicemail on a home phone, should never be given to a member of the patient’s family (unless the patient has provided written consent allowing a member of the family to have access to the patient’s medical records), and should never be faxed to a patient’s place of employment or anywhere else unless the patient has requested it. Test results may end up in the hands of unauthorized individuals, revealing private information that the patient did not wish shared. Any specific instructions from the patient regarding test results should be documented in the patient’s medical record, stating that the test results were faxed or left on the answering machine at the patient’s request.

Special Situations Concerning Release of Patient Information

Drug and Alcohol Treatment
Drug and alcohol rehabilitation records are protected by federal law and cannot be disclosed without the written authorization of the patient, except for a court order or to medical personnel in case of an emergency. The rehabilitation facility may not even acknowledge that an individual attended, is currently undergoing, or has completed a drug and alcohol rehabilitation program.

Public Health and Welfare Needs
Protected health information may be made available, even without the individual’s authorization, to public officials in charge of dealing with serious public health issues, including, for instance, bioterrorism or disaster-relief efforts.

HIV-Related Issues
Human immunodeficiency virus (HIV)-related issues for medical assistants and healthcare practitioners in general may involve the authorization for release of information, patient confidentiality, and penalties if HIV information is released without proper authorization. Ethics and law agree that information disclosed to a physician providing care to a patient is confidential and should never be revealed or released without the express consent of the patient unless required to do so by law. The only exception to this rule is if the patient is threatening bodily harm to other people or to him- or herself.
There are two types of HIV testing: anonymous and confidential. Anonymous testing uses a number code and does not identify the patient by name. Anonymous testing is often done at a clinic for testing. Confidential testing includes a patient’s name, address, date of birth, ethnic origin, and gender. Confidential testing is usually ordered by the patient’s physician.
HIV is a reportable condition; therefore, positive test results, including the patient’s personal data, are reportable to the state department of health. A breach of confidentiality occurs, however, when the physician releases confidential information to a third party, such as an insurance carrier, an employer, or the patient’s family members without the patient’s consent or without a court order. The release form used to obtain the written permission of the patient must clearly state that the release is for HIV-related information, and the form must identify specifically to whom the information is being sent.
The utmost care should be taken by the medical assistant before releasing HIV-related information to a third party. The medical assistant should be sure that written authorization to release HIV-related information is documented in the patient’s medical record. HIV-related information may be recorded in electronic medical records because this information is an important part of the patient’s medical history and medical care. Reported information includes the patient name (if given), date of birth, and ethnicity or race.
If a patient does not have the capability to make decisions for his or her own healthcare, the patient’s healthcare agent may be given this information if he or she requests it and if it may affect decisions made on the patient’s behalf. Penalties for releasing HIV-related information without proper authorization may be severe.

Subpoena Duces Tecum
A subpoena duces tecum is an order to appear in court and bring any papers, books, or information necessary to explain in detail the issue in question. The subpoena may indicate that the person testifying—the physician, office manager, or medical assistant—may be asked to discuss the material needed for court. Appearing before a court of law may be intimidating for any individual, but the individual is simply required to tell the facts.
Original records should never be handed over to the court, so the medical assistant may be asked to make photocopies of the material requested. The material copied should cover only the area requested by the subpoena. Physician approval must be obtained for copying material from the medical record, and the medical office may ask for a fee to compensate the time involved in preparing and copying the requested material.

Rescinding Authorization for Release
Rescinding authorization for release of information may be accomplished by putting the request in writing, dating the form, and submitting the signed form to the appropriate person or medical office. Unfortunately, material already disclosed cannot be rescinded.

Physician-Patient Relationship
The physician-patient relationship is based on mutual respect and trust, governed by contract law, and subject to certain rights and responsibilities.

The Medical Assistant as an Agent of the Physician
The medical assistant is an agent of the physician and must follow the federal and state guidelines required for healthcare professionals because the behavior and actions of the medical assistant may have legal consequences for the physician. The physician may be found guilty of negligence based on the actions of the medical assistant because of a law stating that physicians are liable for the negligent actions of any employee working under their supervision.

Contract Law
Contract law governs agreements, either oral or written, between individuals. The contract establishing the physician-patient relationship is based on an agreement between two parties: The physician makes an offer to treat patients when he or she opens a medical office; the patient accepts the offer when an appointment is made and the patient arrives for the first visit, establishing an implied contract. Because the physician may select the patients he or she will treat, the physician is under no obligation to a person calling for information or care, unless that person is a patient of the physician or an appointment has been scheduled.
Once an individual has been accepted as a patient, the physician has a legal responsibility to provide care with the degree of competency similar to other physicians with comparable medical training. An individual should feel confident that a licensed physician has met the standards necessary to provide quality medical care.
Contracts—such as the one implied between patients and their physicians—are considered valid or legal only when they fulfill certain requirements. Valid contracts must be made by mutual consent between two mentally sound consenting adults or emancipated minors, used only for legal subject matter, and must be for a valid consideration, such as medical treatment. For example, individuals under the influence of drugs or alcohol and mentally impaired individuals are not considered mentally competent, and any contract made with one of these individuals would not be valid and binding. Contracts involving illegal activity, such as prescribing prescription drugs when not needed or selling signed prescription requisitions, are not considered legally binding or valid.

Responsibilities and Rights
Physicians and patients have rights regarding medical care. The physician has the right to select the patients he or she treats, the type of services provided, the office location, and the hours of operation. A physician also has the right to expect payment for the services provided.
The patient has the right to consent to or refuse treatments. If a patient consents to treatment, he or she expects that the treatment provided will be carried out by a competent, caring physician. Patients have the right to expect that all information disclosed in the physician-patient relationship will be kept confidential by the physician and members of the healthcare team. The patient has a financial obligation to the physician for the treatment received and is expected to pay the physician for the medical services rendered.
The medical assistant has a professional responsibility to perform tasks only within the realm of medical assisting knowledge and training. For example, the medical assistant should not offer medical advice to a patient, interpret EKGs, or prescribe medications, because these skills are not included in the standard of care for a medical assistant. The medical assistant is responsible for maintaining patient confidentiality, performing skills competently, keeping his or her skills current, and providing quality care to all individuals under the direct supervision of the physician.
Res ipsa loquitur, meaning 'the thing speaks for itself,' applies to the law of negligence. It means that the negligent action was so obvious, it needs no further examination or explanation.

Guidelines for Third-Party Agreements
A third party in the medical field is usually considered a party other than the patient that is responsible for payment of services rendered for medical care, such as an insurance carrier. The physician has the opportunity to join various third-party payers for patient reimbursement.
Before signing a payer agreement, the physician should carefully read the contract and understand its provisions. The medical assistant is often the individual in charge of requesting payments from such third parties, so he or she must be knowledgeable of third-party policies and procedures.

Professional Liability
Professional liability is a legal obligation that arises from errors, negligent acts, or omissions during the course of someone’s professional practice. Negligence,or medical malpractice, is considered to be the improper treatment or the absence of needed treatment for a patient. Negligence implies that the physician did not act in a manner in which a prudent physician would act. For instance, if a physician performed a procedure in a manner not consistent with the way other competent physicians would have performed it, or failed to order an appropriate test or provide an appropriate treatment that other qualified physicians would have, the physician may be charged with negligence.
Negligence can be broken down into malfeasance (performing a wrong or unlawful act), misfeasance (improperly performing a legal act), and nonfeasance (omitting or failing to perform an act that should have been performed).

In order for the physician to be found guilty of malpractice, certain criteria—the 'four Ds' of negligence—must be met:
1. Duty. The physician accepted the responsibility for the care of the patient when the initial physician-patient contract was established.
2. Derelict. The physician’s failure to provide competent care is an example of dereliction of duty.
3. Direct cause. Proof must be established that the harm caused to the patient was a direct result of the physician’s actions or lack of actions.
4. Damages. The court determines an amount of money that would be sufficient compensation for the patient’s suffering, living expenses, and perhaps rehabilitation.

The statutes of limitation refer to the time period in which a legal malpractice claim may be filed in a court of law. Statutes of limitation laws vary from state to state. Statutes of limitation do not always start at the time of the negligent act; rather, they can start when the negligent act came to the attention of the patient. If the negligent damages involve a child patient, a representative of the court, or a guardian ad litem, may assist in the lawsuit, or the lawsuit may be initiated when the child reaches maturity. The medical assistant should be aware of the specific number of years for the statutes of limitations in the state in which he or she is employed. Medical records should not be destroyed within that time frame because they may be needed for a court case.

Arbitration Agreements
Arbitration is a legal technique used to resolve disputes between parties (such as a physician and a patient) without going to court. A panel of neutral parties who are knowledgeable about the subject will listen to both sides of the dispute and will make an impartial judgment that both sides agree to obey.
Parties may choose arbitration over trying the case in court because the resolution to the dispute is more confidential, less expensive, more convenient and less time-consuming than a court case’s, which could take years. Arbitration statutes apply the same measure of damages as a decision in a court case.

Affirmative Defense
An affirmative defense is one in which the defendant (the person being sued) is trying to win the lawsuit between the patient (the plaintiff) and the physician (the defendant) by acknowledging that he or she shares the blame for the injury received by the patient. Contributory negligence is one of the most common and effectives types of affirmative defense used in malpractice cases. The defense tries to show that the patient’s behavior or negligence was partially responsible for the injury or complication that occurred, although the physician will admit to performing the procedure that led to the patient’s injury. Consent forms could document that the patient was aware of the risks involved in the surgery that was performed and was willing to take those risks. Proving contributory negligence may lessen the damages collected by the plaintiff because he or she was found to be partially responsible for the injury incurred.

Termination of Medical Care
A physician may discontinue treatment of a patient for a variety of reasons. One may be that the patient is not following the physician’s advice. Another may be that a personality conflict between the physician and the patient is interfering with the medical care provided. If, for any reason, the physician chooses to discontinue treating the patient, written notification must be sent to the patient, usually in the form of a certified letter with receipt requested. The certified letter should inform the patient that medical care is being terminated.
Although reasons or details for termination do not have to be listed, many physicians will explain the reason for terminating the physician-patient relationship in the letter. The patient should be given ample time—at least one month—to find another physician before medical care is terminated. The patient should be reassured that the physician will be available for emergency care until a new physician-patient relationship is established. The patient should be notified that his or her medical records will be transferred to the new physician upon written request.
A copy of the dismissal letter and the receipt from the certified letter sent to the patient should be kept in the patient’s medical record as documentation of the patient’s dismissal from the physician-patient contract. Without documentation, the patient may bring a lawsuit against the physician for abandonment.
The patient may terminate the physician-patient contract by requesting in writing that his or her medical records be transferred to another physician or simply by not making new appointments with the physician.

Performing within Ethical Boundaries
Professions have codes of behaviors that members of the profession should follow. Most professional codes include ethical and legal boundaries.

Ethical Standards
Ethics are a set of values—knowing what is right and wrong and acting appropriately. Many sources use the terms ethics and morals interchangeably. Ethics are not laws, although many laws are based on ethics (for example, the Equal Employment Opportunity laws, which make certain types of discrimination against individuals illegal). Principles of professional ethics may include:
- objectivity and impartiality: respecting all patients and providing equal treatment to all patients
- openness and complete honesty: providing all information necessary for treatment and the outcomes of treatment
- confidentiality: never repeating private personal information inappropriately
- responsibility: providing attention and quality care to every patient
The medical assistant’s code of ethics is based on the code of ethics physicians are expected to follow. Being objective, treating patients with respect and confidentiality, and providing the best care possible are behaviors expected of a medical assistant.

Patient Rights
The Patient’s Bill of Rights, developed by the American Hospital Association, is a list of rights that should be accorded to an individual seeking medical treatment.
Patient rights have been discussed in many areas of healthcare, such as patient confidentiality, right to informed consent, and HIPAA regulations for repeating and releasing private patient information. The Patient’s Bill of Rights was adopted by the U.S. Commission on Consumer Protection and Quality in the Healthcare Industry in 1998, summarizing the rights and responsibilities of healthcare providers such as physicians and hospitals, as well as the rights and responsibilities of patients. The bill was designed to help patients feel more comfortable and confident in the healthcare they receive, to stress the importance of a good physician-patient relationship in promoting and maintaining good healthcare, and to emphasize the important role patients must play in the responsibility for their own healthcare.