Health Delivery, Inc
Core Competencies for Medical Assistants
Competency Statement
A. Gathers Clinical
Data and
Accurately
Documents that
Information in the
Patient’s Medical
Record
Compliance Criteria
Obtains:
1. Vital signs
2. Chief Complaint
3. Allergies
4. Patient history
5. Current medications
6. Risk Factors
Requirements for Competency Completion/ Notes
1. Vital Signs include:
 Weight is to be obtained on every patient at every visit. Pediatric patients must
be weighed in dry diaper and no more than an undershirt.
 Height is to be obtained yearly on adult patients and every visit on pediatric
patients. Height is only to be obtained without shoes on using a stadiometer or
infant measuring board.
 Temperature is be measured on every patient at every visit
 Pulse is to be measured on every patient at every visit.
 Respirations are to measured on every patient at every visit
 Blood Pressure is to be obtained at every visit starting at 3 years of age. Proper
cuff size and placement is required. Blood pressure is to be last vital sign checked
to allow for patient to have rest time prior to measurement.
 Head Circumference is to be measured on every pediatric patient at every visit up
to age 2 years.
 Pain Level is to be obtained at every visit using a 0-5 rating scale. Documentation
includes location, description, duration and chronicity
2. Chief complaint is to be completed at every visit and must include the specific reason
for the visit.
3. Allergies are to be reviewed and updated at every visit for every patient
4. A complete history is to be collected at every new patient visit or when it has not been
previously done. The history is to be reviewed at every visit. Complete history includes
Past Medical History, Surgical History, Family History (includes parents, siblings,
grandparents, and children of the patient), Social History, and menstrual history (if
applicable).
5. The medication list is to be reviewed at every visit. Do not remove any medications
from the list. If the patient is not taking a medication that is on the list add text to the
note that reflects that information. Every patient (or parent of a pediatric patient) is be
asked if they are taking any over the counter and or herbal supplements or medications.
Changes to the medication list to reflect prescriptions from hospitals, specialist, etc are to
be done only after review of the notes by the provider.
6. Risk factors are to be assessed for every new patient or if they have not yet assessed on
7. Smoking Status
8. Health Maintenance
B. Maintains
Documentation in
the Medical
Record to Ensure
Accurate and
Complete Tracking
of the Patient’s
Medical
Treatment
Completes
1. MCIR documentation
2. Patient notification of test results
3. Proper chart documentation
related to but not limited to
a. Patient care
b. Telephone contact
4. Tracking/ Order completion
5. Forms
6. Order entry
an established patient. Review of the risk factors is to be done at least yearly.
Assessment includes alcohol use, drug use, and sexual history.
7. Smoking status is to be assessed at every visit. Information regarding smoking
cessation is to be provided to every smoker at every visit.
8. Reviews the Adult Male/Female Intake form and addresses the need for health
maintenance testing or immunizations. Initiates orders for all items.
1. Vaccines must be entered into MCIR within 72 hours of administration.
2. Refer to HDI policy CLIN.79
4. Tracking is to be completed as reports are received. Incomplete orders are to be
addressed at least monthly.
5. All forms are to be completed with all/ any available information prior to delivery to a
provider.
6. Responsible for entering orders for any completed testing during an office visit or any
needed health maintenance measures.
Collects
7. ER visit notes, diagnostic test
results, specialty notes prior to patient
visits
8. Information from patient
regarding other health care providers
that the patient has seen
C. Provides Patient
Education as
Directed and
Documents
Appropriately in
the Patient Record
D. Prepares and
Administers
Medications and
Immunizations
1. Advanced Directives
1. Advanced Directives are to be addressed and documented per HDI protocol CLIN.47
2. PCMH
2. Must be able to accurately provide PCMH information to patients.
1. Properly prepares medications and
vaccines.
2. Administers medications and
immunizations according to policy/
protocol.
3. Recognizes and reports adverse
drug reactions.
2. Refer to CLIN.61 Controlled Substance Documentation and Storage Protocol.
Medications and immunizations may be administered per provider order at a visit,
standing order, or per protocol.
E. Follows
Procedures for
Collecting and
Handling Various
Specimens and
Cultures
F. Properly Uses and
Maintains
Equipment Used
for Providing
Patient Care
G. Performs Tests
and Quality
Controls for CLIA
Waived Testing
4. Administers medications/ vaccines
via:
a. Subcutaneous injection
b. Intramuscular injection
c. Intradermal injection
d. Dropper
e. Oral administration
f. Sublingual administration
g. Nebulizer
1. Throat
2. Wound
3. Stool
4. Urine
5. Sputum
6. Genital
7. Blood via venipuncture
8. Blood via capillary sampling
1. Scales (Adult and Infant)
2. Stadiometer/ Infant measuring
board
3. Thermometer
4. Pulse Oximeter
5. Oxygen tank, nasal cannula, masks
6. Nebulizer and tubing
7. Spirometer
8. Hemocue
9. Tympanometer
10. AED
11. Ear Irrigation System
12. Cryosurgical System
13. EKG
14. Refrigerator/ Freezer
1. Glucometer blood sugar
2. Urinalysis
3. Hemoglobin A1c
4. Hemocue hemoglobin
5. Rapid strep
6. Monospot
7. Rapid HIV
8. Cholesterol
1-10 Must be able to perform test and quality controls per manufacturer instruction.
Tests are to be done in anticipation of need based on the patient’s chief complaint or per
protocol. Refer to In-House Lab Test Reference sheet, CLIN.68, CLIN.13., CLIN.43
H. Prepares and
Assists with
Procedures
I.
Performs
Additional Testing
or Screening per
Protocol or
Provider Order
J. Follows
Instrument
Sterilization
Protocol
K. Properly Handles
Patient
Prescriptions
L. Respond to and
Initiate Written
Communication
9. Hemosure iFOB test
10. Urine pregnancy
1.Initiates consent process
2. Maintains sterile field
Sets up for and participates in
procedures including but not limited
to:
3. Lesion removal
4. Mole excision
5. Colposcopy
6. Pelvic Exam (with and without
PAP)
7. Biopsy
8. Toenail Removal
9. Wound Care
10. IUD placement and/ or removal
11. Implanon insertion/ removal
1. Snellen vision testing
2. ASQ-3 and ASQ-SE developmental
screening
3. PHQ-9
1. Prepares instruments for
autoclaving
2. Properly operates and maintains
the autoclave.
1. Calls in medications appropriately
to pharmacies
2. Appropriately routes prescription
requests via the EMR
3. Properly prepares and routes
medication refill requests for provider
review
4. Initiates and follows up on prior
authorizations as requested by a
provider.
1. Compose and respond to flags in
the EMR
2. Compose and process patient
1. Refer to In-House Test Reference
1.-2. Refer to HDI policy CLIN.19
M. Practice Standard
Precautions
N. Prepare and
Maintain
Examination and
Treatment Areas
O. Accurately and
Appropriately
Accesses
Computer Systems
letters in the EMR.
1. Hand washing
2. Removing contaminated gloves
3. Disposal of biohazardous materials
4. Possesses knowledge of procedure
to follow in the event of an exposure.
1. Room Stocking
2. Anticipate provider needs for visit,
obtain all necessary supplies.
1. Scheduling appointments in the
Centricity system
2. Accesses MCIR
3. Accesses hospital systems to obtain
patient records
6/20/2012
4. Refer to HDI policy CLIN.11
2. MCIR reports are to be available for every pediatric patient at every visit.