INITIAL SELF-STUDY REPORT (IASSR)
MEDICAL ASSISTING EDUCATION REVIEW BOARD (MAERB)
Instructions
The Initial Accreditation Self-Study Report (IASSR) is designed to provide programs who are applying for
initial accreditation a tool by which they can assess and record the quality of their program and its
educational activities in relation to the CAAHEP’s Standards and Guidelines for the Accreditation of
Educational Programs for Medical Assistants. The program is asked to evaluate itself, as outlined by the
Standards and Guidelines, considering national standards, the sponsoring institution’s mission, the
program’s goals and objectives, the design of the curriculum, and the results of the program’s annual
outcomes. The Self-Study provides the context to those outcomes as well as demonstrates compliance
to the Standards and Guidelines.
The MAERB office reviews the Initial Accreditation Self-Study Report (IIASSR) for completion and may
contact the Program Director if there are missing elements. After that initial review, a MAERB member
reviews the IASSR and provides the Site Surveyors who will visit the program with some questions and
ideas. The Site Surveyors then receive the IIASSR approximately two months prior to the visit. After
that, the Team Coordinator will be in contact with the Program Director to plan the site visit and,
perhaps, to ask the Program Director some specific questions about the IIASSR.
If it is determined that the Initial Accreditation Self-Study Report is not complete and if it seems the
program is not yet ready for a site visit, the program will be contacted with questions and there will be
an in-depth review of the Initial Accreditation Self-Study by the MAERB Executive Committee to
determine if the site visit should be held.
In order to easily navigate the Self Study Template in MS Word, you should display the navigation pane.
To do so, click on the View tab and then check the Navigation Pane box.
Initial Accreditation Self Study Report
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You will then be able to click the various headings in order to go to a specific section. The navigation
pane enables you to quickly review all of the sections.
The IASSR template is a MS word fillable form that needs to be completed. Also, there are a number of
appendices that the program will need to submit in order to supplement the information in the IASSR.
Because the document is locked, spell check is not operative. It is recommended that narratives are
created in a separate word document, so that you can copy and paste effectively.
In the following section, you will find a list of all the additional documents that need to be included in
the Appendices. In addition, there is a mandatory naming convention that you will need to follow.
These materials will need to be submitted along with payment for the Comprehensive Review Fees. You
will have received an invoice for that fee at the time your visit date was confirmed. If the fees are not
received, the Self-Study will not be reviewed.
Program Directors will be given instructions about the best method to submit the Initial Accreditation
Self-Study. You will be given instructions to submit the Initial Accreditation Self-Study online. No paper
versions of the Self-Study will be accepted. You must submit the Self-Study Report as a word document.
Self-Study Appendices
Outlined below are the different Appendices required to accompany the Initial-Accreditation Self-Study;
these appendices provide documentation for the CAAHEP Standards. The following charts provide the
mandatory naming conventions in the column “File/Folder Name” for the different folders and files
along with a detailed description of the specific appendices. At the end of this document, you will find a
chart, in “Instructions and Schema for Organizing the Self-Study Submission,” that outlines precisely how
to organize the IASSR for submission.
Even if the specific appendix does not apply to your program, such as consortium agreement, multiple
campus, Teaching Invasive and Protective Competencies Via Distance Education (TIPCDE) Workbook,
Initial Accreditation Self Study Report
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and potential others appendices, you will need to insert a document with the correct name. Inside the
document, just indicate “Not Applicable.”
Standard I Appendices
I.APP
Standard I Folder for Appendices
Type
File
File/Folder Name
IA.InstAcc
Description from Self-Study
Appendix I-A Copy of most recent institutional accreditation letter or
certificate from the sponsoring educational institution recognized by
the U.S. Department of Education indicating the accrediting agency
and the dates of accreditation. It is required, as part of Standard I,
that the program be sponsored by an institution that is
institutionally accredited. If it is a multiple campus program, all
approved sites need to be listed in the document or a supplement to
the document.
Appendix I-B The program history (medical assisting program
length, credit hours and practicum hours) in order to provide the
context for the current program. In addition, include at least one
paragraph that details the program’s ability to meet the required
CAAHEP outcomes, considering the following:
 What resources does the program have that affects the
outcomes?
• How does the curriculum help improve performance on the
outcomes
File
IB.NarrHis
File
IC.OrgCh
Appendix I-C Organizational Chart(s) displaying the school’s
management structure from executive officers to administrative
staff with specific attention paid to the medical assisting program’s
personnel within the institutional structure.
File
ID.ConsAgr
Appendix I-D Consortium agreement, including governance and
lines of authority and responsibilities of each member of the
consortium (if applicable)
Consortium Sponsor - A consortium sponsor is an entity consisting of
two or more members that exists for the purpose of operating an
educational program. In such instances, at least one of the members
of the consortium must meet the requirements of a sponsoring
educational institution, as described in Standard I.A.
File
IE.TIPCDEwrkbk
Initial Accreditation Self Study Report
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Appendix I-E Teaching Invasive or Protective Competencies via
Distance Education (TIPCDE) workbook. Please note that this only
needs to be completed if any of the psychomotor and/or affective
competencies in either “Foundations of Clinical Practices” or “Safety
and Emergency Practices” of the MAERB Core Curriculum are taught
through distance education.
Standard II Appendices
II.APP
Standard II Folder for Appendices
Type
File
File
File
File/Folder Name
IIA.MissSt
IIB.PrgGoals
IIC.ChgsExp
Description from Self-Study
Appendix II-A Copy of the sponsor’s mission statement
Appendix II-B Written Statement of Program Goals
As is outlined in the Standard, every program needs to develop goals
in order to best evaluate the specific needs for program planning,
implementation, and evaluation. Every program responds to this
requirement differently. The goal can be the “minimum
expectation” that is outlined in Standard II.A.
Appendix II-C Description of how the needs and expectations have
changed and how the program has responded to the changes
This narrative should outline how the needs and expectations of the
communities of interest have changed, and the manner in which the
program has responded to those changes. As a general rule,
programs rely upon the Advisory Committee meeting minutes,
surveys of students and employers, and other assessment
documentation. These documents provide the background for how
the program learns about the needs and expectations of the
communities of interest in order to guide the changes.
Folder
IID.AdvMtg
Appendix II-D Copies of Advisory Committee Minutes for past 3
years
The Advisory Committee meeting minutes serve several different
purposes: a record of an annual meeting; a demonstration that the
advisory committee plays a role in helping the Program Director
formulate and revise program goals related to the learning domains;
a monitor of the needs and expectations that the program has and
fulfills; and an indicator of the program’s responsiveness to change.
NOTE: In applying for initial accreditation, advisory meeting minutes
for the year in which the Self-Study was completed need to be
included. You must include at least one year of advisory meeting
minutes, and, if you have 2 or 3 years include those documents as
well. If you don’t have advisory meeting minutes from the past,
state on the relevant document the following notation:
Not necessary for an Initial Accreditation Self-Study.
Initial Accreditation Self Study Report
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Files (3)
File
YY.MMAdv
IIE.MinExp
Appendix II-E Document where the minimum expectations goal is
published
It is required that the minimum expectations goal in Standard II.A be
a part of the program documentation. It can be stated in the
Academic Catalog, the Student Handbook, the Advisory Meeting
Agenda, or the Strategic Plan. The location can vary, but it does
need to be documented.
Standard III Appendices
III.APP
Standard III Folder for Appendices
Type
Folder
File/Folder Name
IIIA.ProgDirWkbk
Description from Self-Study
Appendix III-A Program Director Workbook
File
PDWkbk
Program Director
Workbook
File
JobDes
Program Director Job
Description
File
Resume
Resume
File
Transcript
Transcripts
File
EdThTech
File
Certificate
Educational Theory and
Techniques
documentation
Copy of certificate
documenting
achievement and
currency in one of the
four NCCA-accredited
credentials: CMA
(AAMA), RMA (AMT),
NCMA (NCCT), CCMA
(NHA)
Initial Accreditation Self Study Report
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Folder
IIIB.FacWkbks
Folders
(# of
Faculty)
Folder
Appendix III-B Faculty Workbooks for all faculty teaching courses
unique to the medical assisting program
LastName.First One folder for each MA faculty that contains the workbook and
Initial
supplementary materials that should be named as outlined
below.
File
FacWkbk
Faculty Workbook
File
JobDes
Job Description
File
Resume
Resume
File
Transcript
File
ContEd
File
EdThPract
Transcripts (This material
is necessary if the faculty
is documenting their
qualifications through
education.)
Continuing Education
Certificates (This material
is necessary if the faculty
is documenting their
qualifications through
continuing education.)
Educational Theory and
Techniques
documentation
IIIC.PracCrdWkbks
Appendix III-C Practicum Coordinator Workbooks
Folders (# of LastName.First One folder for each Practicum Coordinator that contains the
Practicum
Initial
workbook and supplementary materials that should be
Coordinators)
named as outlined below.
File
PCWkbk
Initial Accreditation Self Study Report
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Practicum Coordinator
Workbook
File
File
JobDes
Practicum Coordinator
Job Description
File
Resume
Resume
IIID.GrPolCog
Appendix III-D Grading policy, including grading scale and pass
score for cognitive domain objectives
List the specific grading scale (such as A = 93-100% or A = 550-600
points) and specifically indicate what constitutes a passing grade. In
addition, it is important to list the grading value, such as, for
example, the tests are worth 40% of the grade and so on.
File
IIIE.GrPolPsAf
Appendix III-E Grading policy documenting inclusion of the
requirement for successful completion of all psychomotor and
affective domains competencies
List the specific grading policy that applies to the courses for
psychomotor and affective domains objectives and how the
competencies are being conducted. Include the documentation that
informs students that they must successfully achieve every
psychomotor and affective domain in the specific course in order to
pass the course.
Folder
IIIF.Syllabi
Files (#
of
Syllabi)
Folder
Appendix III-F Syllabi for courses in which the MAERB Core
Curriculum objectives are taught and assessed. You do not need to
include General Education courses if they do not include objectives
or competencies from the MAERB Core Curriculum.
Ten Character
Description of
the Courses
(individual
documents)
IIIG.PracPol
Examples:
MA190Admin
MA201MdTrm
MA211Clin1
MA212Clin2
Appendix III-G Description of how practicums are established and
students evaluated throughout their practicum experience, as
appropriate (provide Policy).
Provide the policies and requirements for students to complete the
Practicum requirement, such as the following:
Initial Accreditation Self Study Report
Page 7 of 53
•
•
•
•
•
•
•
•
Files (#
of
Policies)
Ten Character
Description of
the Policies
(individual
documents;
not all these
documents
may apply as
these policies
might be
consolidated
in the
syllabus)
File
IIIH.InvEq
File
IIII.InvSup
File
IIIJ.InvComp
File
IIIK.InvInst
Folder
IIIL.ResAss
Review of course syllabi
Weekly on-campus meeting schedule and/or practicum site
schedule for students
Attendance policy
Uniforms
Professionalism (Appearance, Attitude, Behavior)
Weekly journals
Weekly evaluation of the student by the Practicum site
Final Practicum Evaluation by Practicum Coordinator
Examples:
SyllPrac
SchedPS
AttPol
UnifPol
Prof
WklyJour
WklyEval
FinEvalPP
Syllabus for Practicum
Schedule for Practicum
Attendance Policy
Uniform Policy
Professional Behavior
Weekly Journal
Weekly Evaluation
Final Evaluation
Appendix III-H Inventory of equipment for the Medical Assisting
Program.
Appendix III-I Inventory of supplies for the Medical Assisting
Program.
Appendix III-J Inventory of computer resources available to the
Medical Assisting program.
Appendix III-K Inventory of the instructional reference materials
(e.g., books, periodicals, databases) available to the Medical
Assisting Program.
Appendix III-L The Resource Assessments for the two years prior to
the Resource Assessment included in the Self-Study.
NOTE: In applying for initial accreditation, the program might only
have the resource assessment for the year in which the Self-Study
was completed (See Resource Assessment Form). In that situation,
include the two documents with the following notation:
Not necessary for an initial Accreditation Self-Study.
Initial Accreditation Self Study Report
Page 8 of 53
Files
YY.MMResAss
Standard IV Appendices
IV.APP
Standard IV Folder for Appendices
Type
File
File
File
File/Folder Name
IVA.PrEvalofSt
IVB.PrEvalbySt
IVC.GradSur
Description from Self-Study
Appendix IV-A Instrument/tool used for Practicum Evaluation of
Students
Provide a copy of the tool that you give to the Practicum Supervisor
to evaluate the practicum students. MAERB provides an optional
useful template for programs, which can be found at the MAERB
website www.maerb.org under Documents and labeled “Practicum
Evaluation of Student.” It is a resource that can be adapted or
changed.
Appendix IV-B Instrument/tool used for Practicum Evaluation by
Students
Provide a copy of the instrument/tool that you provide to the
students in order for them to evaluate the Practicum site. MAERB
provides an optional useful template for programs, which can be
found at the MAERB website www.maerb.org under Documents and
labeled “Student Evaluation of the Practicum Site.” It is a resource
that can be adapted or changed.
Appendix IV-C Instrument/tool used for data collection to
determine graduate satisfaction
MAERB provides a mandatory template for programs to use, which
can be found at the MAERB website www.maerb.org under
Documents and labeled “Graduate Survey.” You may add additional
questions to this form, but none of the required questions may be
deleted.
File
IVD.EmplSur
Appendix IV-D Instrument/tool used for data collection to
determine employer satisfaction.
MAERB provides a mandatory template for programs, which can be
found at the MAERB website www.maerb.org under Documents and
labeled “Employer Survey.” You can add additional questions to this
form, but none of the required questions can be deleted.
File
IVE.AdmCoh
Initial Accreditation Self Study Report
Page 9 of 53
Appendix IV-E Admission Cohort explanation—how does the
program, either through a trigger course or a formal admission
process, define its admission cohort.
Outlines how the program determines the correct date for an
admission cohort. According to policy that method can be one of
the following:
• The program’s “Trigger Course,” based on MAERB policy 205
• Institutional Policy: Formal Entrance into the program
This information validates for the surveyors the retention figures in
the ARF by providing an explanation.
MAERB provides a useful template for programs, which can be found
at the MAERB website www.maerb.org under Documents and
labeled “Outcome Assessment Tracking Tool.”
File
IVF.JobPl
Appendix IV-F Resources for job placement of graduates from the
medical assisting program
Each institution has different resources available for students to
guide them in their job hunt. This section allows the program to
discuss, if applicable, what resources are available to students and
what steps the program takes, if any, to help place students.
Options for Responses
• Defines positive placement, taken directly from Standard
IV.B.1
• Discusses the different types of jobs available in the locality
and where students are typically placed
• Discusses the relationship of the practicum to the job
placement
• Discusses what resources (job placement center, career
services, program director network, online job search
service) are available to the students
• Indicates if any job readiness skills (writing resumes, cover
letters, interview practices) are part of the curriculum
• Indicates if the medical assisting department actively
participates in the placement of graduates, or if they just
share information
• Explains what types of follow-up the program does to keep
in contact with the graduates
• Provide PDFs of handouts, brochures, and other materials to
guide students in their job search
Standard V Appendices
V.APP
Standard V Folder for Appendices
Type
File/Folder Name
Initial Accreditation Self Study Report
Page 10 of 53
Description from Self-Study
Folder
VA.Pubs
Appendix V-A Copy of announcements, catalogs, publications,
handbooks, and advertising pertaining to the Medical Assisting
program
A few sample documents are listed below, but it depends upon the
program.
File
StCat
Student Catalog
File
StHand
Student Handbook
File
CrseCat
Course Catalog
File
TechStds
Technical Standards, if used
NOTE: “Technical Standards” can include such
details as “students must be able to lift 20
pounds, climb on step stools, and so on.”
Many programs do not have specific technical
standards and simply use the institutional
admission standards
File
VB.ApplCAHEEP
File
File
File
VC.FacGrvPol
VD.StGrvPol
VE.AffAgr
Folder
VF.ActAffAgr
Files
File
Appendix V-B Document in which the program indicates that it is
applying for CAAHEP accreditation status, based upon MAERB Policy
110. The statement can only be published after a site visit is
scheduled. Programs are not required to make that statement, so
the following statement can be included: “Statement about Initial
Accreditation not included.”
Appendix V-C Copy of the Faculty grievance policy/procedure
Appendix V-D Copy of the Student grievance policy/procedure
Appendix V-E Sample copy of the affiliation agreement or
memorandum of understanding used for practicum sites
Appendix V-F Copies of all the affiliation agreements or
memorandum of understanding with the current active practicum
sites
Abbreviated Name of Practicum
site (10 characters)
VG.AdmPol
Appendix V-G Admissions policy
Include the program’s policy regarding admission into the medical
assisting program, including pre-requisites, if any. It may be that the
medical assisting program uses the institutional policy; if so, that
policy should be included.
File
VH.AdvPl
Initial Accreditation Self Study Report
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Appendix V-H Advanced placement policy(ies), via transfer of
credit, experiential learning, or other method
The program’s policies regarding transfer of credits and credit for
experiential learning need to be included. If your program does not
accept advanced placement, transfer credit, or credit for experiential
learning, there needs to be a policy/statement that explains that to
the students.
File
VI.AssAdvPl
Appendix V-I Tool(s) used to document consistency in awarding
advanced placement.
Provide the type or example of prior-learning assessment for
awarding advanced placement to students.
File
VJ.SftyPol
Policies and procedures assuring adequate safety of patients,
students, and faculty.
General Information
Title of Medical Assisting Program
Address of Institutional Webpage
for Program, if applicable
Award granted
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Important note: If the sponsoring organization has two accredited medical assisting programs, two SelfStudy reports will need to be submitted to the MAERB office for the scheduled site visit. If the
sponsoring organization has a multiple campus program, there is only one combined Self-Study
submitted.
Sponsoring Institution
Mailing Address 1
Mailing Address 2
City, State, Zip
Institution Phone Number (include
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hyphens)
Website
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Name and Contact information for person with the central responsibility for the preparation and
submission of the report. MAERB recognizes that the Self-Study is a collaborative activity.
Name and Credentials
Title
Mailing Address
City, State, Zip
Phone Number (include hyphens)
Initial Accreditation Self Study Report
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Email
Contact Information
Chief Executive Officer (to whom all correspondence will be directed)
Name and Credentials
Title
Mailing Address
City, State, Zip
Phone Number (include
hyphens)
Email
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Dean or comparable administrator (MAERB wants the information about the person to whom medical
assisting Program Director reports)
Name and Credentials
Title
Mailing Address
City, State, Zip
Phone Number (include
hyphens)
Email
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Program Director
Name and Credentials
Title
Mailing Address
City, State, Zip
Phone Number (include
hyphens)
Email
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Practicum Coordinator 1
Name and Credentials
Title
Mailing Address
City, State, Zip
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Initial Accreditation Self Study Report
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Phone Number (include
hyphens)
Email
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Practicum Coordinator 2 (if applicable)
Name and Credentials
Title
Mailing Address
City, State, Zip
Phone Number (include
hyphens)
Email
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Practicum Coordinator 3 (if applicable)
Name and Credentials
Title
Mailing Address
City, State, Zip
Phone Number (include
hyphens)
Email
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If there are more than three Practicum Coordinators, please list the names below and be sure to include
their Practicum Coordinator Workbook in Appendix III-C, along with all the other Practicum Coordinator
Workbooks:
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Standard I
Sponsoring Educational Institution
What agency accredits the post-secondary
institution that sponsors the organization?
Date of the most recent comprehensive
institutional accreditation action.
Initial Accreditation Self Study Report
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Date of the next comprehensive institutional
review.
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Consortium Sponsor
Is the program sponsored by a consortium?
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If applicable, provide the consortium name and address:
Consortium Name
Mailing Address
City, State, Zip
Phone Number
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Program Design
Length of program in months
Total credit or clock hours
Type of academic terms (semester, quarters,
blocks)
Number of cohorts admitted per year
Total current enrollment
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Program Modality (Please note that programs that are 100% online have a separate Self-Study
template)
Is any portion of the program offered via distance
education?
If so, what percentage of the program is offered
through distance education?
Are any of the psychomotor and/or affective
competencies in either “Foundations of Clinical
Practices” or “Safety and Emergency Practices” of
the MAERB Core Curriculum taught through
distance education?
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If the answer is yes about assessing the psychomotor and/or affective competencies in either
“Foundations of Clinical Practices” or “Safety and Emergency Practices,” please complete Appendix I-E.
Sponsoring Organization Support for Accreditation
In making the decision to seek initial accreditation for the medical assisting program, both the
sponsoring organization and the medical assisting program commit to the Standards and Guidelines.
Outline the process by which the sponsoring organization and the program determined that seeking
Initial Accreditation Self Study Report
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CAAHEP accreditation was a program goal. Just as some hypothetical prompts, the questions below
may be helpful:

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
For example, did the program submit a business, a proposal, a statement of intent for review?
Did the program need to follow a specific internal institutional process?
How does the sponsoring organization ensure that the provisions of these Standards and
Guidelines will be met?
What commitments has the sponsoring organization made in terms of resources for
accreditation?
How has the sponsoring organization helped or supported the Program Director’s involvement in
MAERB?
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Standard II
Program Goals and Outcomes
As is outlined in the Standard, every program needs to develop written goals in order to best evaluate
the specific needs for program planning, implementation, and evaluation. Every program responds to
this requirement differently. The goal can be the “minimum expectation” that is outlined in Standard
II.A, but programs often add specifics to that minimum goal.
Briefly comment on how the program goals are compatible with the mission of the sponsor and the
expectations of the communities of interest.
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Appropriateness of Goals and Learning Domains
Describe the need and expectations of each of your communities of interest. What outcomes
(retention, job placement, employer survey participation, employer satisfaction, graduate survey
participation, graduate satisfaction, exam participation, exam passage) are the most important for that
specific community of interest? You will need to identify the top two outcomes that are the most
important to each community of interest.
As the program is applying for initial accreditation, you are learning about the needs and expectations,
so you will find that it can be a good and fruitful conversation to focus on these outcomes.
Communities of Interest
Students
Graduates
Faculty
Sponsor Administration
Employers
Briefly describe the needs and
expectations of each of your
communities of interest.
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Initial Accreditation Self Study Report
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Identify the top two outcomes
that are most important to each
community of interest.
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Physicians
Public
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Name
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Agency/Organization
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Advisory Committee
Representative
Current Student
Graduate
Faculty
Sponsor Administration
Employers
MD, DO, NP, or PA
Public (an individual who has never
been employed in a healthcare
environment and is not employed at an
institution of higher learning with
CAAHEP accredited programs)
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Briefly describe the background and work history of the Public Member to ensure that the qualifications
comply with MAERB Policy 230:
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List the dates on which the Advisory Committee has met over the past three years. If the program does
not have a history of meeting prior to the most recent year, just mark the field N/A:
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Minimum Expectations
Where is the minimum expectation goal
(Standard II.C) published? (Advisory Committee
Minutes, College Catalog, Student Handbook, and
Initial Accreditation Self Study Report
Page 17 of 53
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so on?) How are the program’s goals
communicated to its communities of interest?
Does the program have any additional educational goals (beyond entry level and the MAERB Core
Curriculum) for the students? Some examples included phlebotomy certificates, advanced coding, and
so on. Explain those specific goals. Then explain how the students achieve the minimum expectations,
as it is required that the student achieve the entry level goals. Also, describe the methods by which the
additional goals were developed.
If this does not apply to the program, indicate “Not Applicable.”
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Standard III
Budget: Sufficiency of Program Resources
What month does the program’s fiscal year begin?
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List, combining if necessary, the actual medical assisting program budget from all funding sources in
order to fill out the applicable amounts. If any of the items are in a shared budget with other
departments, estimate the medical assisting portion based on a percentage of usage.
Description
Expenditures of previous
fiscal year
Current Fiscal Year
budget
Projected budget for next
fiscal year, if available
Fiscal Year
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Full-time faculty salaries
Part-time faculty salaries
Other salaries
Clerical Support
Support Staff
Equipment
Supplies
Computer Resources
Initial Accreditation Self Study Report
Page 18 of 53
Instructional Reference Materials
Faculty Continuing Education
Staff Continuing Education
Other
Other
Other
Totals
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Personnel
Briefly comment on what the Program Director does in regards to program effectiveness, including
outcomes, organization, administration, continues review, and planning and development.
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Briefly comment on the processes by which the Practicum Coordinator selects and approves appropriate
practicum, provides orientation of the practicum experience, provides oversight of the practicum
experience and ensures appropriate and sufficient evaluation of student achievement in the practicum
experience. Detail precisely how the Practicum Coordinator oversees the students placed at the
practicum site.
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Please fill out the following demographic information about the personnel within the Medical Assisting
Department. If the Program Director or the Practicum Coordinator also serve as program faculty,
include them in this chart.
Number of full-time faculty
Number of part-time faculty
Number of full-time clerical and/or support staff
Number of part-time clerical and/or support staff
Initial Accreditation Self Study Report
Page 19 of 53
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Curriculum
Describe how the program is designed in order to ensure that there is an appropriate sequence of
classroom, laboratory, and clinical activities. In other words, how does the program ensure that
students have been taught and assessed on the specific cognitive objectives prior to being taught the
psychomotor and affective competencies that are linked to those cognitive objectives? And how does
the program ensure that all the applicable cognitive objectives, and psychomotor and affective
competencies are achieved prior to the start of any practicum?
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How many hours of practicum are required in the program?
In what written documentation (Program Handbook, practicum
syllabi, and so on) are the students informed that the practicum
hours are unpaid?
In what written documentation (agreement, orientation materials
and so on) are the practicum site supervisors informed that the
practicum hours are unpaid?
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Describe what type of services that the medical assisting student has access to in the following areas.
Please include any other support services that are applicable.
Academic Advising
Personal Counseling
Academic Tutoring
Financial Aid
Computer Resources
Library
On-line Academic Resources
Health Services
Career Counseling
Other Support Service
Other Support Service
Other Support Service
Other Support Service
Initial Accreditation Self Study Report
Page 20 of 53
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Standard IV
Student Evaluation
How does the program inform the students of the academic progress that they are making in the
program and how does the student access that information?
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Outcomes
CAAHEP accreditation is based upon outcomes, ensuring that programs have met specific thresholds in
the outcomes that the program has met for more information about the thresholds and the importance
of the outcomes, please see MAERB policy 205.
In applying for initial accreditation, the program is attesting that it has begun the process of collecting
information in order to demonstrate that it is achieving two specific goals:
1. adhering to the practice of collecting and maintaining data
2. evaluating its processes in order to best achieve the outcomes
Retention
What trigger course and/or formal admission process does the program use in order to designate its
admission cohort? You can summarize your response from Appendix IV-E.
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Outline below the process that has begun in order to track and/or collect the raw data for the outcome.
Outcomes
Retention (60% Threshold)
Job Placement (60%
Threshold)
Graduate Survey
Participation (30%
Threshold)
Graduate Satisfaction (80%
Threshold)
Employer Survey
Participation (30%
Threshold)
Employer Satisfaction (80%
Threshold)
Exam Participation (30%
Threshold)
Comment on how the program tracks and/or collects
the raw data for the outcome.
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Initial Accreditation Self Study Report
Page 21 of 53
Exam Passage (60%
Threshold)
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Describe the method that the program uses to encourage graduates or students to take a credentialing
exam?
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For programmatic summative measures, what type of tracking mechanism or process (such as master
competency checklist, detailed gradebook, electronic portfolio and so on) does the program use to
ensure that all graduates have achieved all of the MAERB Core Curriculum psychomotor and affective
competencies?
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Standard V
Publications and Disclosure
Institutional Accreditation
status, including name, address,
and phone number of the
accrediting agency
Program Accreditation Status,
including name, address,
website address and phone
number of the accrediting
agency
Academic Calendar
Admissions policies and
practices
Technical Standards, if used by
the program
Policy on Advanced Placement
Policy on Transfer of Credits
Policy on Experiential Learning
Criteria for graduation
Policies and processes by which
students may perform clinical
Where is it published (catalog,
student handbook, brochure,
webpage, other misc.)?
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Page numbers or specific
website address
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Initial Accreditation Self Study Report
Page 22 of 53
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work while enrolled in the
program
Practicum policies (supervision,
non-remuneration)
Number of credits required for
completion of the program
Tuition/fees and other costs
required to complete the
program
Policies and processes for
student withdrawal from
program
Policies and processes for
refunds
Student grievance policy
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Lawful and Non-discriminatory Practices
How does the sponsoring institution ensure that all activities, such as student and faculty recruitment,
student admission, and faculty employment practices, are non-discriminatory and in accordance with
federal and state statutes, rules, and regulations.
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Where is the faculty grievance procedure published? And how is it made available to faculty?
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Safeguards
How are faculty, students, and any participants who are acting in a patient role provided information
about the health and safety policies of the medical assisting program?
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Student Records
Where are student records for admission, advisement, counseling and evaluation maintained?
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Initial Accreditation Self Study Report
Page 23 of 53
Agreements
Does the affiliation agreement/memorandum of understanding for the practicum do the following?
Describe the relationship, roles, and
responsibilities of the sponsor and that entity
Include a statement that the students must be
supervised
Include a statement that the students must not
receive compensation for services as part of the
practicum
Choose an item.
Choose an item.
Choose an item.
If you responded “no” to any of these questions, please explain. If not, just state “Not Applicable.”
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Initial Accreditation Self Study Report
Page 24 of 53
Additional Forms for Standard III
Resource Assessment
Program
Resource
What program
Outcomes are
affected by that
resource and how?
(for example,
retention or job
placement or so
on)
Tools used to assess
the resource (for
example, surveys,
evaluations,
interviews)
Dates of
Measurement
Results
Action Plan
(designed for
maintenance or
improvement)
Action Plan FollowUp/Status
Program
Director
Practicum
Coordinator
Faculty
Advisory
Committee
Clerical Staff
Support
Staff
(Registrar,
Admissions,
Financial
Aid, and so
on)
Finances
Offices
Classrooms
Laboratories
Ancillary
Student
Facilities
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Initial Accreditation Self Study Report
Page 25 of 53
(library,
food
services,
student
health
services,
learning
center)
Practicum
Affiliations
Equipment
Supplies
Computer
Resources
Instructional
Reference
Material
Faculty/Staff
Continuing
Education
Other
Other
Other
Other
Other
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Curriculum Course List
It is not necessary to list the general education courses. The only courses that should be listed are the ones that contain the MAERB Core
Curriculum.
Course
Number
Course Title
# of Lecture
Hours
Initial Accreditation Self Study Report
Page 26 of 53
# of Lab
hours
# of credits
(if applicable)
Cognitive
objectives
Psychomotor/Affective
Competencies taught
(yes/no)
Term Taken
Prerequisite, if
any
taught
(yes/no)
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Curriculum Map
Cognitive Objectives
Assessment Tool
Crosswalk (if applicable)
List what type of assessment tool is
used to measure the achievement of
this objective. Be detailed (multiple
choice, essay, presentation, fill-in the
blank, report, and so on)
If the program creates its own course
learning objectives and does not use the
number and precise language of the
cognitive objective on the syllabus,
include the course learning objective
listed on syllabus that covers the specific
objective.
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Course Number (eg,
MED 101, MED 107)
I.C Anatomy & Physiology
I.C.1. Describe structural organization of the human body
I.C.2. Identify body systems
I.C.3. Describe:
a. body planes
Initial Accreditation Self Study Report
Page 27 of 53
b. directional terms
c. quadrants
d. body cavities
I.C.4. List major organs in each body system
I.C.5. Identify the anatomical location of major organs in
each body system
I.C.6. Compare structure and function of the human body
across the life span
I.C.7. Describe the normal function of each body system
I.C.8. Identify common pathology related to each body
system including:
a. signs
b. symptoms
c. etiology
I.C.9. Analyze pathology for each body system including:
a. diagnostic measures
b. treatment modalities
I.C.10. Identify CLIA waived tests associated with common
diseases
I.C.11. Identify the classifications of medications including:
a. indications for use
b. desired effects
c. side effects
d. adverse reactions
I.C.12. Identify quality assurance practices in healthcare
I.C.13. List principles and steps of professional/provider
CPR
I.C.14. Describe basic principles of first aid as they pertain
to the ambulatory healthcare setting
II.C Applied Mathematics
Initial Accreditation Self Study Report
Page 28 of 53
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II.C.1. Demonstrate knowledge of basic math
computations
II.C.2. Apply mathematical computations to solve
equations
II.C.3. Define basic units of measurement in:
a. the metric system
b. the household system
II.C.4. Convert among measurement systems
II.C.5. Identify abbreviations and symbols used in
calculating medication dosages
II.C.6. Analyze healthcare results as reported in:
a. graphs
b. tables
III.C Infection Control
III.C.1. List major types of infectious agents
III.C.2. Describe the infection cycle including:
a. the infectious agent
b. reservoir
c. susceptible host
d. means of transmission
e. portals of entry
f. portals of exit
III.C.3. Define the following as practiced within an
ambulatory care setting:
a. medical asepsis
b. surgical asepsis
III.C.4. Identify methods of controlling the growth of
microorganisms
III.C.5. Define the principles of standard precautions
Initial Accreditation Self Study Report
Page 29 of 53
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III.C.6. Define personal protective equipment (PPE) for:
a. all body fluids, secretions and excretions
b. blood
c. non-intact skin
d. mucous membranes
III.C.7. Identify Center for Disease Control (CDC)
regulations that impact healthcare practices
IV.C Nutrition
IV.C.1. Describe dietary nutrients including:
a. carbohydrates
b. fat
c. protein
d. minerals
e. electrolytes
f. vitamins
g. fiber
h. water
IV.C.2. Define the function of dietary supplements
IV.C.3. Identify the special dietary needs for:
a. weight control
b. diabetes
c. cardiovascular disease
d. hypertension
e. cancer
f. lactose sensitivity
g. gluten-free
h. food allergies
Initial Accreditation Self Study Report
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V.C Concepts of Effective Communication
V.C.1. Identify styles and types of verbal communication
V.C.2. Identify types of nonverbal communication
V.C.3. Recognize barriers to communication
V.C.4. Identify techniques for overcoming communication
barriers
V.C.5. Recognize the elements of oral communication
using a sender-receiver process
V.C.6. Define coaching a patient as it relates to:
a. health maintenance
b. disease prevention
c. compliance with treatment plan
d. community resources
e. adaptations relevant to individual patient
needs
V.C.7. Recognize elements of fundamental writing skills
V.C.8. Discuss applications of electronic technology in
professional communication
V.C.9. Identify medical terms labeling the word parts
V.C.10. Define medical terms and abbreviations related to
all body systems
V.C.11. Define the principles of self-boundaries
V.C.12. Define patient navigator
V.C.13. Describe the role of the medical assistant as a
patient navigator
V.C.14. Relate the following behaviors to professional
communication:
a. assertive
b. aggressive
c. passive
Initial Accreditation Self Study Report
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V.C.15. Differentiate between adaptive and non-adaptive
coping mechanisms
V.C.16. Differentiate between subjective and objective
information
V.C.17. Discuss the theories of:
a. Maslow
b. Erikson
c. Kubler-Ross
V.C.18. Discuss examples of diversity:
a. cultural
b. social
c. ethnic
VI.C Administrative Functions
VI.C.1. Identify different types of appointment scheduling
methods
VI.C.2. Identify advantages and disadvantages of the
following appointment systems
a. manual
b. electronic
VI.C.3. Identify critical information required for scheduling
patient procedures
VI.C.4. Define types of information contained in the
patient’s medical record
VI.C.5. Identify methods of organizing the patient’s
medical record based on:
a. problem-oriented medical record (POMR)
b. source-oriented medical record (SOMR)
VI.C.6. Identify equipment and supplies needed for
medical records in order to:
Initial Accreditation Self Study Report
Page 32 of 53
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a. Create
b. Maintain
c. Store
VI.C.7. Describe filing indexing rules
VI.C.8. Differentiate between electronic medical records
(EMR) and a practice management system
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VI.C.9. Explain the purpose of routine maintenance of
administrative and clinical equipment
VI.C.10. List steps involved in completing an inventory
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VI.C.11. Explain the importance of data back-up
VI.C.12. Explain meaningful use as it applies to EMR
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VII.C Basic Practice Finances
VII.C.1. Define the following bookkeeping terms:
a. charges
b. payments
c. accounts receivable
d. accounts payable
e. adjustments
VII.C.2. Describe banking procedures as related to the
ambulatory care setting
VII.C.3. Identify precautions for accepting the following
types of payments:
a. cash
b. check
c. credit card
d. debit card
VII.C.4. Describe types of adjustments made to patient
accounts including:
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a. non-sufficient funds (NSF) check
b. collection agency transaction
c. credit balance
d. third party
VII.C.5. Identify types of information contained in the
patient's billing record
VII.C.6. Explain patient financial obligations for services
rendered
VIII.C Third Party Reimbursement
VIII.C.1. Identify:
a. types of third party plans
b. information required to file a third party claim
c. the steps for filing a third party claim
VIII.C.2. Outline managed care requirements for patient
referral
VIII.C.3. Describe processes for:
a. verification of eligibility for services
b. precertification
c. preauthorization
VIII.C.4. Define a patient-centered medical home (PCMH)
VIII.C.5. Differentiate between fraud and abuse
IX.C Procedural and Diagnostic Coding
XI.C.1. Describe how to use the most current procedural
coding system
XI.C.2. Describe how to use the most current diagnostic
coding classification system
XI.C.3. Describe how to use the most current HCPCS level II
coding system
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XI.C.4. Discuss the effects of:
a. upcoding
b. downcoding
XI.C.5. Define medical necessity as it applies to procedural
and diagnostic coding
X.C Legal Implications
X.C.1. Differentiate between scope of practice and
standards of care for medical assistants
X.C.2. Compare and contrast provider and medical
assistant roles in terms of standard of care
X.C.3. Describe components of the Health Insurance
Portability & Accountability Act (HIPAA)
X.C.4. Summarize the Patient Bill of Rights
X.C.5. Discuss licensure and certification as they apply to
healthcare providers
X.C.6. Compare criminal and civil law as they apply to the
practicing medical assistant
X.C.7. Define:
a. negligence
b. malpractice
c. statute of limitations
d. Good Samaritan Act(s)
e. Uniform Anatomical Gift Act
f. living will/advanced directives
g. medical durable power of attorney
h. Patient Self Determination Act (PSDA)
i. risk management
X.C.8. Describe the following types of insurance:
a. liability
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b. professional (malpractice)
c. personal injury
X.C.9. List and discuss legal and illegal applicant interview
questions
X.C.10. Identify:
a. Health Information Technology for Economic
and Clinical Health (HITECH) Act
b. Genetic Information Nondiscrimination Act
of 2008 (GINA)
c. Americans with Disabilities Act Amendments
Act (ADAAA)
X.C.11. Describe the process in compliance reporting:
a. unsafe activities
b. errors in patient care
c. conflicts of interest
d. incident reports
X.C.12. Describe compliance with public health statutes:
a. communicable diseases
b. abuse, neglect, and exploitation
c. wounds of violence
X.C.13. Define the following medical legal terms:
a. informed consent
b. implied consent
c. expressed consent
d. patient incompetence
e. emancipated minor
f. mature minor
g. subpoena duces tecum
h. respondent superior
i. res ipsa loquitor
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j. locum tenens
k. defendant-plaintiff
l. deposition
m. arbitration-mediation
n. Good Samaritan laws
XI.C Ethical Considerations
XI.C.1. Define:
a. ethics
b. morals
XI.C.2. Differentiate between personal and professional
ethics
XI.C.3. Identify the effect of personal morals on
professional performance
XII.C Protective Practices
XII.C.1. Identify:
a. safety signs
b. symbols
c. labels
XII.C.2. Identify safety techniques that can be used in
responding to accidental exposure to:
a. blood
b. other body fluids
c. needle sticks
d. chemicals
XII.C.3. Discuss fire safety issues in an ambulatory
healthcare environment
XII.C.4. Describe fundamental principles for evacuation of
a healthcare setting
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XII.C.5. Describe the purpose of Safety Data Sheets (SDS)
in a healthcare setting
XII.C.6. Discuss protocols for disposal of biological
chemical materials
XII.C.7. Identify principles of:
a. body mechanics
b. ergonomics
XII.C.8. Identify critical elements of an emergency plan for
response to a natural disaster or other emergency
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Assessment Tool
Course Number (eg,
MED 101, MED 107)
List what type of assessment tool is
used to measure the achievement of
this competency. Be detailed (Checkoff sheet, roleplaying with rubric,
work product)
If the program creates its own course
learning objectives and does not use the
number and precise language of the
psychomotor competency on the
syllabus, include the course learning
objective listed on syllabus that covers
the specific competency.
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Psychomotor Competencies
I.P Anatomy & Physiology
I.P.1. Measure and record:
a. blood pressure
b. temperature
c. pulse
d. respirations
e. height
f. weight
g. length (infant)
h. head circumference (infant)
i. pulse oximetry
I.P.2. Perform:
a. electrocardiography
b. venipuncture
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c. capillary puncture
d. pulmonary function testing
I.P.3. Perform patient screening using established
protocols
I.P.4. Verify the rules of medication administration:
a. right patient
b. right medication
c. right dose
d. right route
e. right time
f. right documentation
I.P.5. Select proper sites for administering parenteral
medication
I.P.6. Administer oral medications
I.P.7. Administer parenteral (excluding IV) medications
I.P.8. Instruct and prepare a patient for a procedure or a
treatment
I.P.9. Assist provider with a patient exam
I.P.10. Perform a quality control measure
I.P.11. Obtain specimens and perform:
a. CLIA waived hematology test
b. CLIA waived chemistry test
c. CLIA waived urinalysis
d. CLIA waived immunology test
e. CLIA waived microbiology test
I.P.12. Produce up-to-date documentation of
provider/professional level CPR
I.P.13. Perform first aid procedures for:
a. bleeding
b. diabetic coma or insulin shock
c. fractures
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d. seizures
e. shock
f. syncope
II.P Applied Mathematics
II.P.1. Calculate proper dosages of medication for
administration
II.P.2. Differentiate between normal and abnormal test
results
II.P.3. Maintain lab test results using flow sheets
II.P.4. Document on a growth chart
III.P Infection Control
III.P.1. Participate in bloodborne pathogen training
III.P.2. Select appropriate barrier/personal protective
equipment (PPE)
III.P.3. Perform handwashing
III.P.4. Prepare items for autoclaving
III.P.5. Perform sterilization procedures
III.P.6. Prepare a sterile field
III.P.7. Perform within a sterile field
III.P.8. Perform wound care
III.P.9. Perform dressing change
III.P.10. Demonstrate proper disposal of biohazardous
material
a. sharps
b. regulated wastes
IV.P Nutrition
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IV.P.1. Instruct a patient according to patient’s special
dietary needs
V.P Concepts of Effective Communication
V.P.1. Use feedback techniques to obtain patient
information including:
a. reflection
b. restatement
c. clarification
V.P.2. Respond to nonverbal communication
V.P.3. Use medical terminology correctly and pronounced
accurately to communicate information to providers and
patients
V.P.4. Coach patients regarding:
a. office policies
b. health maintenance
c. disease prevention
d. treatment plan
V.P.5. Coach patients appropriately considering:
a. cultural diversity
b. developmental life stage
c. communication barriers
V.P.6. Demonstrate professional telephone techniques
V.P.7. Document telephone messages accurately
V.P.8. Compose professional correspondence utilizing
electronic technology
V.P.9. Develop a current list of community resources
related to patients’ healthcare needs
V.P.10. Facilitate referrals to community resources in the
role of a patient navigator
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V.P.11. Report relevant information concisely and
accurately
VI.P Administrative Functions
VI.P.1. Manage appointment schedule using established
priorities
VI.P.2. Schedule a patient procedure
VI.P.3. Create a patient’s medical record
VI.P.4. Organize a patient’s medical record
VI.P.5. File patient medical records
VI.P.6. Utilize an EMR
VI.P.7. Input patient data utilizing a practice management
system
VI.P.8. Perform routine maintenance of administrative or
clinical equipment
VI.P.9. Perform an inventory with documentation
VII.P Basic Practice Finances
VII.P.1. Perform accounts receivable procedures to patient
accounts including posting:
a. charges
b. payments
c. adjustments
VII.P.2. Prepare a bank deposit
VII.P.3. Obtain accurate patient billing information
VII.P.4. Inform a patient of financial obligations for
services rendered
VIII.P Third Party Reimbursement
VIII.P.1. Interpret information on an insurance card
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VIII.P.2. Verify eligibility for services including
documentation
VIII.P.3. Obtain precertification or preauthorization
including documentation
VIII.P.4. Complete an insurance claim form
IX.P Procedural and Diagnostic Coding
IX.P.1. Perform procedural coding
IX.P.2. Perform diagnostic coding
IX.P.3. Utilize medical necessity guidelines
X.P Legal Implications
X.P.1. Locate a state’s legal scope of practice for medical
assistants
X.P.2. Apply HIPAA rules in regard to:
a. privacy
b. release of information
X.P.3. Document patient care accurately in the medical
record
X.P.4. Apply the Patient’s Bill of Rights as it relates to:
a. choice of treatment
b. consent for treatment
c. refusal of treatment
X.P.5. Perform compliance reporting based on public
health statutes
X.P.6. Report an illegal activity in the healthcare setting
following proper protocol
X.P.7. Complete an incident report related to an error in
patient care
XI.P Ethical Considerations
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XI.P.1. Develop a plan for separation of personal and
professional ethics
XI.P.2. Demonstrate appropriate response(s) to ethical
issues
XII.P Protective Practices
XII.P.1. Comply with:
a. safety signs
b. symbols
c. labels
XII.P.2. Demonstrate proper use of:
a. eyewash equipment
b. fire extinguishers
c. sharps disposal containers
XII.P.3. Use proper body mechanics
XII.P.4. Participate in a mock exposure event with
documentation of specific steps
XII.P.5. Evaluate the work environment to identify unsafe
working conditions
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Assessment Tool
Course Number (eg,
MED 101, MED 107)
List what type of assessment tool is
used to measure the achievement of
this competency. Be detailed (Checkoff sheet, roleplaying with rubric,
work product)
If the program creates its own course
learning objectives and does not use the
number and precise language of the
affective competency on the syllabus,
include the course learning objective
listed on syllabus that covers the specific
competency.
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Affective Competencies
I.A Anatomy & Physiology
I.A.1. Incorporate critical thinking skills when performing
patient assessment
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I.A.2. Incorporate critical thinking skills when performing
patient care
I.A.3. Show awareness of a patient’s concerns related to
the procedure being performed
II.A Applied Mathematics
II.A.1. Reassure a patient of the accuracy of the test results
III.A Infection Control
III.A.1. Recognize the implications for failure to comply
with Center for Disease Control (CDC) regulations in
healthcare settings
IV.A Nutrition
IV.A.1. Show awareness of patient’s concerns regarding a
dietary change
V.A Concept of Effective Communication
V.A.1. Demonstrate:
a. empathy
b. active listening
c. nonverbal communication
V.A.2. Demonstrate the principles of self-boundaries
V.A.3. Demonstrate respect for individual diversity
including:
a. gender
b. race
c. religion
d. age
e. economic status
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f. appearance
V.A.4. Explain to a patient the rationale for performance
of a procedure
VI.A Administrative Functions
VI.A.1. Display sensitivity when managing appointments
VII.A Basic Practice Finances
VII.A.1. Demonstrate professionalism when discussing
patient's billing record
VII.A.2. Display sensitivity when requesting payment for
services rendered
VIII.A Third Party Reimbursement
VIII.A.1. Interact professionally with third party
representatives
VIII.A.2. Display tactful behavior when communicating
with medical providers regarding third party requirements
VIII.A.3. Show sensitivity when communicating with
patients regarding third party requirements
IX.A Procedural and Diagnostic Coding
IX.A.1. Utilize tactful communication skills with medical
providers to ensure accurate code selection
X.A Legal Implications
X.A.1. Demonstrate sensitivity to patient rights
X.A.2. Protect the integrity of the medical record
XI.A Ethical Considerations
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XI.A.1. Recognize the impact personal ethics and morals
have on the delivery of healthcare
XII.A Protective Practices
XII.A.1. Recognize the physical and emotional effects on
persons involved in an emergency situation
XII.A.2. Demonstrate self-awareness in responding to an
emergency situation
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Instructions and Schema for Organizing the Self-Study Submission
In the section above, you received detailed information about the Appendices that accompany the Self-Study that you submit. In this section,
there is an extended discussion about how to organize the Appendices, using the naming convention that is outlined in the earlier section for
your submission of the Self-Study. Here are some general rules of practice for organizing the Self-Study submission.

Even if the specific appendix does not apply to your program, such as consortium agreement, multiple campus, Teaching Invasive and
Protective Competencies Via Distance Education (TIPCDE) Workbook, and potential others appendices, you will need to insert a document
with the correct name. Inside the document, just indicate “Not Applicable.”

There may be times in which you need to submit a folder rather just a file, due to the nature of the program’s documentation. If that is the
case, follow the general practice and logic that is implicit in the naming convention.
You may only use PDF files, Excel Files, or Word files for the Appendices. The examples below are in Word just for the sake of convenience.

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Then the folders that contain the Appendices should follow this pattern:
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Example of documents for a Faculty Workbook
folder:
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Examples of Documents for a Practicum
Coordinator Workbook Folder:
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Initial Accreditation Self Study Report
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