Urinalysis

Patient Communication

Patient education about urinalysis should use simple language (6th-grade reading level). Verify understanding with teach-back: ask the patient to explain in their own words what was discussed. Provide written instructions to reinforce verbal education. Address cultural and language barriers using certified interpreters, not family members, for medical discussions.

Documentation

Documentation of urinalysis in the medical office uses ICD-10-CM: Diagnosis coding with alphanumeric codes, 3-7 characters, maintained by WHO/NCHS.

Examples: J06.9: Upper respiratory infection; E11.65: Type 2 diabetes with hyperglycemia; S52.501A: Fracture of lower end of radius, initial encounter.

All documentation must be timely, accurate, legible, and include the provider signature. Late entries must be labeled as such with the date of the original event.

Safety Considerations

Safety considerations for urinalysis in the medical office include proper technique and universal precautions.

Intradermal injections: angle 10-15 degrees bevel up, sites include Inner forearm. Maximum volume: 0.1 mL max. Needle: 26-27G, 3/8 to 5/8 inch.

Workplace Applications

Workplace application of urinalysis requires fluency in medical terminology:

Common Errors

Medical assistants must avoid these errors related to urinalysis:

• Syncope: lower head, apply cool compress, do not leave unattended
• Hemolysis: redraw, often caused by vigorous mixing or small-gauge needle
• Nerve injury: remove needle immediately if patient reports shooting pain
• Failing to verify patient identity using two identifiers before any procedure

Clinical Significance

Medical assistants encountering urinalysis should be familiar with associated laboratory values. CBC reference ranges:

• Hematocrit: 37-47% (F), 42-52% (M)
• WBC: 4,500-11,000/uL
• RBC: 4.2-5.9 million/uL