Key Takeaways
- The medical assistant's scope of practice is defined by state law and varies by state — always practice within your scope
- Informed consent requires the patient to understand the procedure, risks, benefits, alternatives, and consequences of refusal before agreeing
- Medical malpractice requires four elements (the "4 Ds"): Duty, Dereliction (breach of duty), Direct cause, and Damages
- The Patient Bill of Rights guarantees the right to informed consent, privacy, the right to refuse treatment, and the right to access medical records
- Advance directives include living wills (treatment preferences) and durable power of attorney for healthcare (designated decision-maker)
- Mandatory reporting requirements include suspected child abuse, elder abuse, certain communicable diseases, and gunshot/stab wounds
- Respondeat superior (Latin for "let the master answer") holds the employer liable for employee actions performed within the scope of employment
- The AAMA Code of Ethics establishes professional conduct standards including patient confidentiality, integrity, and commitment to continuing education
Legal & Ethical Practice
Understanding medical law and professional ethics is essential for every medical assistant. This section covers the legal framework of healthcare, patient rights, consent, malpractice, and ethical standards that guide medical assistant practice.
Scope of Practice
The scope of practice defines what a medical assistant is legally allowed to do. Key points:
- Scope of practice is determined by state law — it varies from state to state
- Medical assistants work under the direct supervision of a licensed physician
- Medical assistants can perform clinical and administrative tasks as delegated by the physician
- Medical assistants cannot independently diagnose, prescribe, or provide treatment plans
- Always check your state's specific regulations — some states have practice acts for medical assistants, others do not
Tasks Medical Assistants Generally CAN Perform
- Take vital signs and patient histories
- Administer medications as directed by the physician
- Perform CLIA-waived lab tests
- Perform ECGs
- Assist with minor procedures
- Give injections (IM, SubQ, ID) as ordered
- Draw blood (phlebotomy)
- Process insurance claims and scheduling
Tasks Medical Assistants Generally CANNOT Perform
- Diagnose conditions or diseases
- Prescribe medications
- Perform surgery or invasive procedures independently
- Practice independently without physician supervision
- Provide medical advice beyond the scope of patient education
- Administer IV medications (in most states)
Types of Consent
| Type | Description | Example |
|---|---|---|
| Informed consent | Patient understands and agrees to procedure after explanation of risks, benefits, alternatives, and consequences of refusal | Surgical consent form |
| Implied consent | Consent assumed by patient's actions | Patient holds out arm for blood draw |
| Express consent | Consent given verbally or in writing | Patient says "yes, I agree to the test" |
| Informed refusal | Patient understands and declines a recommended treatment | Patient declines recommended vaccination after discussion |
Elements of Informed Consent
- Nature of the procedure — what will be done
- Risks — potential complications and side effects
- Benefits — expected outcomes
- Alternatives — other treatment options available
- Consequences of refusal — what may happen without treatment
- Patient questions — opportunity to ask questions and receive answers
- Voluntary agreement — patient agrees without coercion
Important: The physician is responsible for obtaining informed consent (explaining the procedure). The medical assistant may witness the signing but should not be the one explaining the procedure to the patient.
Medical Malpractice
Medical malpractice is a type of negligence that occurs when a healthcare provider fails to meet the standard of care, resulting in harm to the patient.
The Four Ds of Malpractice (All Four Must Be Proven)
| Element | Description | Example |
|---|---|---|
| Duty | A provider-patient relationship existed | Patient is under the care of the physician |
| Dereliction | The provider breached (failed to meet) the standard of care | Medical assistant gives wrong medication |
| Direct cause | The breach directly caused the injury | The wrong medication caused an allergic reaction |
| Damages | The patient suffered measurable harm | Physical injury, additional medical costs, pain and suffering |
Key Legal Concepts
| Concept | Definition |
|---|---|
| Standard of care | Level of care a reasonably competent provider would give in similar circumstances |
| Negligence | Failure to exercise reasonable care |
| Respondeat superior | "Let the master answer" — employer is liable for employee actions within scope of work |
| Res ipsa loquitur | "The thing speaks for itself" — negligence is obvious (e.g., sponge left inside patient) |
| Statute of limitations | Time limit for filing a malpractice lawsuit (varies by state, typically 2-3 years) |
| Good Samaritan laws | Protect volunteers who provide emergency care in good faith from liability |
| Subpoena | Legal order to appear in court or produce records |
| Subpoena duces tecum | Legal order to bring specific documents (medical records) to court |
Patient Rights
The Patient Bill of Rights
Key patient rights include:
- Right to informed consent — understand and agree to treatment
- Right to refuse treatment — even if recommended by the physician
- Right to privacy — HIPAA-protected health information
- Right to access medical records — request and receive copies
- Right to confidentiality — health information shared only on a need-to-know basis
- Right to considerate and respectful care — without discrimination
- Right to know the identity of healthcare providers
- Right to a second opinion — seek another provider's evaluation
- Right to advance directives — document end-of-life wishes
Advance Directives
| Document | Purpose |
|---|---|
| Living will | Specifies treatment preferences if the patient becomes unable to make decisions (e.g., no CPR, no ventilator) |
| Durable power of attorney for healthcare (healthcare proxy) | Designates a person to make medical decisions if the patient cannot |
| DNR (Do Not Resuscitate) | Physician order to withhold CPR if the patient's heart or breathing stops |
| POLST (Physician Orders for Life-Sustaining Treatment) | Portable medical order specifying treatment wishes (more specific than a living will) |
Mandatory Reporting
Medical assistants and other healthcare providers are mandated reporters required by law to report:
| Reportable Condition | Report To |
|---|---|
| Suspected child abuse or neglect | Child Protective Services (CPS) |
| Suspected elder abuse or neglect | Adult Protective Services (APS) |
| Certain communicable diseases | Local/state health department (varies by state) |
| Gunshot and stab wounds | Law enforcement |
| Dog bites (in many states) | Local health department |
| Suspected domestic violence | Varies by state |
Important: Mandatory reporting does not require the patient's consent. The duty to report overrides patient confidentiality in these specific situations.
Ethics in Medical Assisting
AAMA Code of Ethics (Key Principles)
- Render service with respect for human dignity
- Respect patient confidentiality (except when required by law to report)
- Uphold the honor and high principles of the profession
- Participate in continuing education to maintain competency
- Strive to improve knowledge and skills for better patient care
- Be aware of and observe all applicable laws
Medical Assistant Creed
- Believe in the principles and purposes of the medical assisting profession
- Be dedicated to providing competent service
- Aspire to render greater service through continuing education
- Place professional principles above personal interests
Ethical Principles in Healthcare
| Principle | Definition | Example |
|---|---|---|
| Autonomy | Patient's right to make their own decisions | Respecting a patient's choice to refuse treatment |
| Beneficence | Doing good; acting in the patient's best interest | Providing the best possible care |
| Nonmaleficence | "Do no harm" — avoiding actions that cause harm | Double-checking medications before administration |
| Justice | Treating all patients fairly and equitably | Providing the same quality of care regardless of background |
| Fidelity | Faithfulness to duty and commitments | Maintaining patient confidentiality |
| Veracity | Truthfulness | Providing honest information about a diagnosis |
Workplace Safety
OSHA (Occupational Safety and Health Administration)
OSHA establishes and enforces workplace safety standards. Key requirements for medical offices:
- Bloodborne Pathogen Standard: Exposure control plan, PPE, sharps safety, hepatitis B vaccination
- Hazard Communication Standard (HazCom/GHS): Safety Data Sheets (SDS) for all hazardous chemicals, labeling requirements, employee training
- Personal Protective Equipment (PPE): Gloves, gowns, masks, eye protection — provided at no cost to employees
- Needlestick Safety and Prevention Act: Requires use of safety-engineered sharps devices
- Injury and illness records: OSHA Form 300 (log), Form 300A (summary), Form 301 (incident report)
Safety Data Sheets (SDS)
Formerly called Material Safety Data Sheets (MSDS), SDS documents must be maintained for every hazardous chemical in the workplace. Key sections include:
| Section | Content |
|---|---|
| Section 1 | Identification (product name, manufacturer, emergency phone) |
| Section 2 | Hazard identification |
| Section 4 | First-aid measures |
| Section 5 | Firefighting measures |
| Section 7 | Handling and storage |
| Section 8 | Exposure controls and personal protection |
SDS documents must be readily accessible to all employees at all times.
Emergency Preparedness
Medical offices should have plans for:
- Medical emergencies: Cardiac arrest, anaphylaxis, seizures — maintain crash cart/AED
- Fire: Know evacuation routes, fire extinguisher locations (PASS: Pull, Aim, Squeeze, Sweep)
- Natural disasters: Earthquake, tornado, hurricane protocols
- Active threat/violence: Run, Hide, Fight protocol
- Equipment failure: Backup procedures for power outages, computer downtime
Patient Termination Process
A provider may terminate the patient-provider relationship, but must follow proper legal procedures:
- Written notification by certified mail with return receipt requested
- Adequate notice — typically 30 days to allow the patient to find a new provider
- Continued emergency care during the 30-day notice period
- Offer to transfer records to the patient's new provider
- Document everything in the patient's medical record
Failure to follow these steps may constitute patient abandonment, which is a form of negligence.
Patient Abandonment
Patient abandonment occurs when a provider terminates the relationship without proper notice, leaving the patient without access to necessary care. Examples include:
- Refusing to see an established patient without proper notice
- Leaving during a procedure without arranging a qualified replacement
- Failing to follow up on critical test results
All four elements of medical malpractice (the "4 Ds") must be proven for a successful claim. Which of the following is NOT one of the 4 Ds?
A physician explains a surgical procedure to a patient, including risks, benefits, and alternatives. The patient agrees and signs a consent form. The medical assistant witnesses the signature. This is an example of:
The legal doctrine of "respondeat superior" means:
Which of the following are mandatory reporting requirements for healthcare providers? (Select all that apply)
Select all that apply
A document that designates a person to make medical decisions for a patient who becomes unable to make decisions for themselves is called a durable power of attorney for ___.
Type your answer below
Arrange the stages of the Kubler-Ross grief model in the correct order.
Arrange the items in the correct order
Match each ethical principle to its definition.
Match each item on the left with the correct item on the right
Which document specifies a patient's treatment preferences if they become unable to make medical decisions?
A patient holds out their arm when the medical assistant prepares to draw blood. This is an example of:
The OSHA Hazard Communication Standard (HazCom) requires that medical offices maintain which document for every hazardous chemical in the workplace?
A medical assistant notices bruises in various stages of healing on a 4-year-old patient whose parent provides an inconsistent explanation. The medical assistant should:
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