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Oct 26th, 2014
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Question description

LP1.2 Assignment: Procedures and Work Products

Directions: This is a two part assignment. First, in Kinn’s The Medical Assistant Study Guide use the Records Release Authorization to complete Part IV: Releasing Medical Records on page 102. The information on the form should be made up by you. This portion of the assignment is worth 5 points.

Next, in Kinn’s The Medical Assistant textbook, read Procedure 14-2 on page 243 and then use the Informed Consent for Treatment Form to complete. This portion of the assignment is worth 5 points.

Before filling out the forms, it will be necessary to download and save the documents to your computer. Make sure to include your name in the title (for example, LP1.2 Work Product_Walters).

Submit this assignment to your instructor via the dropbox “LP1.2 Assignments: Procedures and Work Products.” This assignment is worth 10 points and will be graded according to the scoring guide below.

Scoring Guide (10 Points)
Rating Scale
5 Work meets or exceeds criterion at a high level of competence.
4 Work reflects an understanding of criterion with minor misunderstandings/misconceptions.
3 Criterion partially met, but one or more important concepts/skills are missing or flawed.
2 Work reflects an attempt to meet criterion, but significant misunderstandings/misconceptions are apparent.
1 - 0 Criterion not met or work is absent.
1. Student correctly completes and submits the Records Release Authorization form.
2. Student correctly completes and submits the Informed Consent for Treatment form.

Part V. Complete an Authorization to Release Medical Records from using your name as the patient.


TO_____________________ _____________________________

  Doctor or Hospital





________________________________________ILLNESS AND/OR





    (If relative, state relationship)


I give my consent to Dr. ___________________________________ and assistants,_________________ to perform:


  (Name of treatment/ procedure. Description in lay & medical terms)

I am aware that, during the procedure, other procedures might be needed. I give my consent to do these procedures as needed.

I give my consent to receive anesthesia and/or drugs I may need.  I know that all procedures and anesthetics have risks like stroke, heart attack, respiratory failure and death.  Some other risks are tooth and nerve damage, and skin/soft tissue injury. 

I give my consent for blood and/or blood products if I need them.  I know that all blood and blood products can cause allergic response, fever and hives. I k now the blood bank screens donors for infections and diseases like hepatitis and HIV/AIDS, but I am aware there is a risk of infection.


Patient Initials


If I DO NOT want blood or blood products, I will put my initials in this box 

and fill out the “Statement of Refusal for Blood/ Blood Components”

I give my consent for the ­­­­­­­­­­­­­­­­­­____________  facility to use or to dispose of any substance removed as part of my treatment or procedure. The substance might be body fluids, tissues and organs.  I am aware that the substance might be looked at or used in education for other health care providers.  This material will be disposed of using routine methods.


Patient Initials


If I DO NOT want to be told of the risks listed below, I will put my initials in this box.

I know that each person reacts in a different way to treatments and procedures. Therefore, the results cannot be certain.  My questions have been answered about the procedure.  I have been told:

  1.  The treatment or procedure that my doctors plan to do

  2.  What to expect from the treatment or procedure (the benefits).

  3.  The serious risks of this treatment or procedure.  Some of these risks can happen despite all steps   being taken to prevent them

  4.  Other types of treatment that could be used.  This includes no treatment.

  5.  Whether or not the treatment or procedure is uncommon.

Some of the known serious possible risks for the procedure are:

Severe loss of blood, infection, stroke or heart attack that can lead to death or permanent or partial disability,

Other known serious possible risks are: 

Patient Initials

I know I can change my mind about the consent at any time before treatment.

I know that I must tell the health care staff caring for me if I change my mind. 

[img src="file:///C:\Users\Warnette\AppData\Local\Packages\oice_15_974fa576_32c1d314_3362\AC\Temp\msohtmlclip1\01\clip_image001.png" height="149" width="722">

Health Care Provider obtaining consent (PRINT NAME & INITIAL)    SIGNATURE of person giving consent (legally authorized to do so)

[img src="file:///C:\Users\Warnette\AppData\Local\Packages\oice_15_974fa576_32c1d314_3362\AC\Temp\msohtmlclip1\01\clip_image002.png" height="30" width="722">

DATE SIGNED   TIME  AM/PM  Relationship to patient (if applicable)

[img src="file:///C:\Users\Warnette\AppData\Local\Packages\oice_15_974fa576_32c1d314_3362\AC\Temp\msohtmlclip1\01\clip_image003.png" height="2" width="722">

Name of interpreter:  Second witness for telephone consent:

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