CMSA key terms

The six-link sequence by which a pathogen spreads: infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host. Breaking any link stops transmission.

Practices that reduce the number and spread of microorganisms in the clinical environment, such as hand hygiene, glove use, and surface disinfection. Also called clean technique.

Technique that keeps objects and areas free of all microorganisms, including spores. Used for sterile procedures such as catheter insertion, dressing changes, and assisting in minor surgery.

Infection-control measures applied to every patient regardless of diagnosis, including hand hygiene, gloves, gown, mask, eye protection when splash is likely, and safe sharps handling.

Extra precautions used beyond standard precautions for specific pathogens, grouped as contact, droplet, and airborne. Each type specifies room placement, mask type, and protective equipment for staff and visitors.

Barrier items worn to prevent exposure to blood, body fluids, and airborne agents. Includes gloves, gown, mask or respirator, and eye protection; must be removed in the correct order to avoid self-contamination.

Cleaning hands with soap and water or alcohol-based rub at defined moments, such as before patient contact and after glove removal. The single most effective way to prevent healthcare-associated infection.

A work area kept free of all microorganisms, created by opening sterile packaging without touching the contents. Only sterile items may enter; anything touching the border or an unsterile surface is contaminated.

The introduction of microorganisms or foreign material onto a sterile item or clean surface, making it unsterile. In sterile technique, any questionable item is discarded and the procedure restarted.

An infection a patient acquires during care for another condition, not present or incubating at admission. Prevention relies on hand hygiene, device care, environmental cleaning, and antibiotic stewardship.

An accidental needlestick or cut from a contaminated sharp object. The exposed worker should wash the site, report immediately, and follow post-exposure evaluation and prophylaxis protocols.

Contact of mucous membranes, broken skin, or a puncture with blood or other potentially infectious material. Requires immediate washing, source evaluation, and testing for hepatitis B, hepatitis C, and HIV.

A patient's voluntary agreement to a procedure after receiving and understanding its purpose, risks, benefits, and alternatives. The provider obtains it; the assistant may witness the signature but cannot explain the procedure.

The tasks and decisions a healthcare worker is legally permitted to perform based on training, licensure, and state law. Working outside it, even at a supervisor's request, is unsafe and may be illegal.

The legal and ethical duty to protect patient health information from unauthorized disclosure. It continues after employment ends and applies to conversations, records, screens, and faxes.

Individually identifiable health information held or transmitted by a covered entity, including names, dates, record numbers, and images. Its use and disclosure are restricted by federal privacy rules.

The principle that only the least amount of patient information needed for a task should be accessed, used, or shared. It applies to staff questions, record requests, and billing communications.

A written, signed patient authorization permitting disclosure of specified records to a named party, with an expiration date and right to revoke. It must be verified before records are sent.

A legal document stating a patient's wishes for future medical care, such as a living will or durable power of attorney for healthcare. It guides treatment when the patient cannot speak for themselves.

The level of care a reasonably competent professional with similar training would provide in similar circumstances. It is the benchmark used to judge whether negligence occurred.

Failure to meet the standard of care, causing harm. Four elements must be shown: a duty to the patient, a breach of that duty, causation, and actual damages.

The core measurements of body function: temperature, pulse, respiration, blood pressure, and often oxygen saturation and pain. They establish a baseline and reveal changes requiring action.

The force of blood against arterial walls, recorded as systolic over diastolic pressure in millimeters of mercury. Technique includes correct cuff size, arm support at heart level, and rest before measurement.

A drop in blood pressure on standing, commonly at least 20 mmHg systolic or 10 mmHg diastolic, often with dizziness. Measured by comparing lying, sitting, and standing readings.

The rhythmic expansion of arteries with each heartbeat, assessed for rate, rhythm, and strength. Common sites are radial, brachial, carotid, and apical; rate is counted for a full 30 or 60 seconds.

The exchange of oxygen and carbon dioxide, observed as breaths per minute along with depth and rhythm. Count without telling the patient, since awareness alters the breathing pattern.

A noninvasive estimate of arterial oxygen saturation using a finger or ear probe. Readings below normal suggest hypoxemia; poor perfusion, nail polish, and motion can cause false results.

The checks performed before giving any drug: right patient, right medication, right dose, right route, right time, and right documentation. Many facilities add right reason and right to refuse.

The systematic comparison of a patient's current medications with new orders at transitions of care to prevent omissions, duplications, and interactions. Includes prescriptions, over-the-counter drugs, and supplements.

An unintended, harmful response to a medication given at a normal dose, ranging from rash to anaphylaxis. It must be documented, reported, and communicated to the prescriber.

A severe, rapidly progressing allergic reaction with airway swelling, low blood pressure, hives, and breathing difficulty. It is a medical emergency requiring epinephrine and immediate summoning of help.

Giving medication by a route other than the digestive tract, such as injection or infusion. It requires sterile technique, correct needle and site selection, and safe sharps disposal.

Delivery of medication into muscle tissue, commonly at the deltoid or ventrogluteal site. Site selection depends on volume, patient age, and muscle mass; the needle is inserted at a 90-degree angle.

The ratio between a drug's toxic dose and its effective dose. A narrow index, as with warfarin or digoxin, means small changes in blood level can cause harm, so monitoring is required.

Blood drug measurements taken at the highest and lowest points of concentration to guide dosing for drugs with narrow safety margins. Timing of the draw is critical to the result's meaning.

Obtaining blood, urine, tissue, or other samples for laboratory analysis. Correct patient identification, container, timing, and labeling determine whether results are valid.

Puncture of a vein to obtain blood, usually with a needle and evacuated tube system. Requires site selection, tourniquet timing under one minute, and proper order of draw.

The required sequence for filling blood tubes during collection to prevent additive cross-contamination. Blood cultures come first, then tubes for coagulation, serum, and additive-containing tests.

Breakdown of red blood cells that releases hemoglobin into the sample, distorting many test results. Causes include vigorous shaking, small needles, prolonged tourniquet time, and delayed processing.

Documented record of who collected, handled, and stored a specimen at each step, used for legal or employment testing. Any gap in the record can invalidate the result.

A timed antiseptic scrub of hands and forearms before sterile procedures to reduce resident flora. It is followed by sterile gowning and gloving without touching nonsterile surfaces.

Cutting and withdrawing surgical stitches after adequate wound healing, typically 5 to 14 days depending on site. The area is cleaned first, and the wound is checked for separation or infection.

Separation of the edges of a closed surgical wound, sometimes with drainage or organ exposure. It is a complication to report immediately rather than treat with simple dressing changes.

The legal document of a patient's care, including history, findings, orders, results, and communications. Entries must be accurate, dated, timed, signed, and made promptly.

Documentation that records only findings outside defined normal limits or significant events. It relies on clearly established standards and is efficient but requires disciplined use.

Documentation added after the fact for care already provided, clearly labeled with the actual date and time of the entry. It must never be backdated to appear contemporaneous.

Findings that can be observed, measured, or verified, such as vital signs, rashes, and lab values. They are distinguished from symptoms the patient reports, which are subjective.

Information the patient reports about their experience, such as pain level, nausea, or fatigue. It is documented in the patient's own words and cannot be independently verified.

Purposeful conversation that supports the patient's understanding and emotional comfort, using open questions, reflection, and silence. It avoids judgment, false reassurance, and unexplained jargon.

Confirming understanding by asking the patient to explain or demonstrate instructions in their own words. It reveals gaps that a simple "Do you understand?" question would miss.

A patient's ability to obtain, process, and act on health information. Low literacy is common and hidden; plain language, pictures, and limited key points improve teaching.

Assigning a task to another team member while retaining accountability for the outcome. The task must be within the delegate's training and legal scope, and the patient must be stable.