question

Medical Assistant Duties & Responsibilities

answer

Telephone coverage, scheduling, maintenance of medical records, management of all correspondences

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Qualities of a Medical Assistant

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Dependability, courtesy, initiative, interpersonal skills

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Medical Profession Liability

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The physician-patient relationship is an implied contract in which the physician is expected to assess & treat the pt with the same amount of knowledge, skill, & judgement as another physician under the same circumstances.

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Rules that must be followed under physician-patient relationship

answer

1.Patient is expected to compensate the physician for all services provided 2. The patient is expected to adhere to any directions/guidance provided by the physician 3. If the physician terminates the contract, the pt must be provided with advance notice of these intentions as well as given enough time to seek the services of another physician.

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Consent To Treat

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Once the physician-patient relationship has been entered, the physician must have consent to treat the patient. In most cases, the patient's implied consent is apparent through their action of seeking the services of the physician. In certain situations, the patient's informed consent is necessary, in a written form that states their understanding of the prescribed treatment as well as its risks.

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Good Samaritan Act

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States that a volunteer is not held liable for any civil damages that may occur as a result of their efforts to provide emergency care.

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Patient's Bill of Rights

answer

Developed to ensure the fairness and effectiveness of the healthcare system, as well as to encourage people to take an interest in the improvement of their health. -8 sections -Patient is provided with a copy on first visit, or it is visibly posted within the facility.

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HIPPA Patient Privacy Rule

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Establishes regulations for the use & disclosure of PHI and mandates that all patients be provided a copy of privacy polices when treated in a doctor's office or when admitted to any HCF (health care facility).

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Vocabulary

answer

1. Abandonment: The discontinuation of medical care without proper notice. 2. Arbitration: The usage of an impartial third party for the hearing and determination of a dispute. 3. Battery: The unlawful use of force or violence. 4. Negligence: The failure to provide the necessary care that is required. Statutes: Laws enacted by the legislative branch of a government.

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Phone Etiquette: Steps to ensure proper phone etiquette

answer

1. Answer promptly & kindly 2. Properly speak into phone 3. Give caller undivided attention 4. Speak clearly & distinctly 5. Be courteous 6. Ask permission before placing on hold if necessary. 7. Never get upset at an angry caller; remain calm & composed.

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Verbal & Nonverbal Communication

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Verbal: The use of words spoken; sounds, words, speaking, & language Nonverbal: Eye contact, body language, facial expressions, symbolic expressions.

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Appointments: Considerations when selecting an appointment book

answer

Size in consideration of desk space available, accommodation of # of appointments made, comfort for writing, space for details necessary.

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Usage of Matrix

answer

Times physician is not available, hospital rounds, meetings, days off, holidays, breaks for meals.

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Types of Scheduling: Wave Scheduling

answer

Usually see 4 patients an hour. All are scheduled for the top of the hour, and are seen in order of their arrival.

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Modified Wave

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In 1 hour time frame; two patients are given own specific time, and two are told to arrive at the same time (e.g., 10:30)

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Double Booking

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2 or more patients scheduled with the same physician at the same time, overbooking. Not good schedule planning; causes many delays.

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Scheduling New Patients

answer

1. Obtain and verify general information 2. Gather appropriate information regarding a patient referral (if applicable) 3. Determine patient's cc (chief complaint). 4. Make patient aware of various dates & times available to be seen. 5. Enter appropriate time for appointment. 6. Determine financial arrangements (insurance, cash, etc.). 7. Provide directions as needed. 8. Verify information and appointment time/date.

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Scheduling Conflicts

answer

1.Late patients: Advise to arrive 30 minutes prior to appointment time. 2.Emergency Calls: Arrangements made to be seen same day if available 3.Cancelled Appointments: Remove original time, schedule new appointment. 4.Unscheduled Patients: Accommodate as best as possible, ensure patient that making appointment is the best way to ensure care. 5.Failed appointments: Notate in patient's chart and appointment book, and attempt to reschedule. 6.Delayed patient wait time: Explain reason (without giving too much detail) and provide patient with the option to reschedule if desired by the patient.

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Types of Mail

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1. Express Mail: available 365 days per year, for items up to 70lbs in weight, and up to 108" in height. 2. First Class Mail: letters, postal cards, postcards, and business reply mail 3. Priority Mail: First Class mail weighing more than 13oz. 4. Certified Mail: proof of delivery 5. Bulk Mailing: mailing large volumes of information which is presorted by zipcode.

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Health Insurance: Verification of Insurance Benefits

answer

1. Identify type of insurance or managed care plan. 2. Make copies of card; front and back. 3. Call carrier to verify services and benefits. 4. Record this information in medical record and VOB (verification of benefits) form. 5. Provide patient with form listing requirements and restrictions of plan, and have them read and sign the form. 6. Collect deductible/co-payment if applicable.

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Types of Health Insurance

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1. Individual Policies: Usually ineligible to receive government paln; high premiums and limited benefits. 2. Group Policies: Provides coverage for employees under a single contract. This type of coverage is characterized by greater benefits, and low premiums. 3. Government Plans: Available to large groups of people who meet specific eligibility criteria. TRICARE, Medicare, Medicaid, and Worker's Compensation are examples.

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Insurance Terms

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1. Assignment of Benefits: An arrangement by which a patient requests that their health benefit payments be made directly to the physician. 2. Benefit: The amount payable by the carrier toward the cost of services for which the patient is eligible for. 3. Deductible: The amount an individual must pay for health care expenses before insurance covers the cost. 4. Co-payment: The portion of a service fee that the patient must pay. 5. Policy: A document that describes the insurance coverage for an individual or property. 6. Premium: The amount the patient pays for an insurance contract.

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Usual, Customary, and Reasonable (UCR) or Covered Expenses

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An amount customarily charged for or covered for similar services and supplies which are medically necessary, recommended by a doctor, or required for treatment.

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Waiting Period

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A period of time when you are not covered by insurance for a particular reason or problem.

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Medical Records Management: Creating a Medical Record

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1. Determine if new or established patient. 2. Obtain required general information. 3. Enter the information into patient history form. 4. Review the form for accuracy 5. Enter patient's name into computerized ledger 6. Assemble forms, prepare folder, and file.

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Components of the Medical Record

answer

1. Personal and Medical History: Past illnesses, surgical operations, patient's daily health habits. 2. Patient's Family History: Health/diseases of family members and a record of causes of death. 3. Patient's Social History: Included information regarding the patient's lifestyle: e.g., tobacco use, alcohol use, drug use. 4. Patient's CC (Chief Complaint): A statement of the patient's symptoms. 5. Diagnosis: A decision made based on the information regarding the patient's history and the results of the doctor's examination.

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SOAP approach to documenting

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A format for progress notes based on the letters of the word SOAP. S: Subjective Impressions: given by patient O: Objective Clinical Evidence: test results, observed A: Assessment/Diagnosis: probably diagnosis P: Plans for further studies, treatment, or management: treatment

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SOMR record organization

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Source-Oriented Medical Record. Divided into sections: Laboratory, progress notes, etc. In chronological order, most recent is on top in each section.

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POMR record organization

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Problem-Oriented Medical Record. Problems are numbered. Has database: Demographics, profile history, cc, past assessments and test results; Treatment plan: procedures, medications, instructions; Progress notes: continuous care notes.

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Filing: Indexing Rules

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1. last name, first name, middle/initial. 2. Hyphenated portion of name is one unit. Ex: Anna Smith-Meyer = Smithmeyer, Anna. 3. Apostrophes are NOT used in filing. 4. Titles and terms of seniority are only used to distinguish from an identical name. 5. When indexing a company, articles such as "the" and "a" are not used. Ex: The Mandarin Office = Mandarin Office

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Alphabetical Filing

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Folders are arranged in the same sequence of the alphabet. Ensure the filing cabinet has enough space for proper distribution of files within each letter.

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Numerical Filing

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An alphabetic cross-reference is used to categorize materials with digits. Patients are assigned in a consecutive order. Records are filed backwards in groups. Ex: Terminal digit filing.

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Subject Filing

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Either an alphabetic or alphanumeric code is assigned to general correspondence.

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Tickler File

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A collection of date labeled file folders used as a reminder for time sensitive matters or other important information. Used as a follow up method. Checked daily.

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Medical Terminology

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Combining forms, prefixes, and suffixes

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Arthr/o

answer

joint

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Bi/o

answer

Life

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Cardi/o

answer

heart

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Carcin/o

answer

cancerous

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Cephal/o

answer

head

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Cerebr/o

answer

cerebrum

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Cyt/o

answer

cell

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Denti/o

answer

teeth

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Derm/o

answer

skin

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Electr/o

answer

electrical activity

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Enter/o

answer

intestines

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Fet/o

answer

fetus

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Gastr/o

answer

stomach

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Hepat/o

answer

liver

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Iatr/o

answer

treatment, physician

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Leuk/o

answer

white

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Nephr/o

answer

kidney

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Oste/o

answer

bone

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Path/o

answer

disease

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Ren/o

answer

kidney

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Rhin/o

answer

nose

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Sarc/o

answer

flesh

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Thromb/o

answer

clotting

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Ur/o

answer

urinary tract

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-al

answer

pertaining to

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-algia

answer

pain

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-dynia

answer

pain

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-ectomy

answer

excision, removal

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-emia

answer

blood condition

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-genic

answer

produced by/ pertaining to producing

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-globin

answer

protein

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-itis

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inflammation of

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-oma

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tumor

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-osis

answer

condition, usually abnormal

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-pathy

answer

disease condition

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-sis

answer

state of; condition

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-ectomy

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removal of

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-graphy

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process of recording

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-metry

answer

process of measurement

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-scopy

answer

a visual examination

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-stomy

answer

a new opening

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-tomy

answer

incision

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-tripsy

answer

process of crushing

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-graph

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instrument for recoring

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-meter

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instrument to measure

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-scope

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instrument to visually or aurally examine

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-tome

answer

instrument to cut

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-tripter

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instrument to crush

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-trite

answer

instrument to crush

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Ante-

answer

before, in front of

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Anti-

answer

against

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Brady-

answer

slow

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Dia-

answer

through, complete

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End-, Endo-

answer

within

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Epi-

answer

above, upon

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Hyper-

answer

excessive, above

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Hypo-

answer

deficient, below

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Peri-

answer

around, surrounding

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Pre-

answer

before

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Sub-

answer

below, under

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Body Systems

answer

Systems are groups of organs working together to perform complex functions. Viscera is the term for internal organs.

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Musculoskeletal System

answer

Functions: support, movement, protection. Organs: muscles, bones, joints, bone marrow.

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Integumentary System

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Functions: protection Organs: skin, hair, nails

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Gastrointestinal System

answer

Functions: nutrition Organs: stomach, intestines

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Urinary System

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Functions: elimination of nitrogenous waste Organs: kidneys, bladder, ureters, urethra

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Reproductive System

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Functions: reproduction Organs: ovaries, testes

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Blood/Lymphatic System

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Functions: transportation Organs: blood cells

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Immune System

answer

Functions:protection Organs: lymph glands

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Cardiovascular System

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Functions: transportation Organs: heart, vessels

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Respiratory System

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Functions: delivers oxygen to cells and removes carbon dioxide Organs: lungs, bronchi, trachea.

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Nervous/Behavioral System

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Functions: receive/process information Organs: brain, nerves, mind

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Endocrine System

answer

Functions: effects changes through chemical messengers Organs: pancreas, thyroid

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Body Cavities

answer

5 Cavaties: Cranial, Spinal, Thoracic, Abdominal, Pelvic

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Cranial Cavity

answer

Brain; dorsal cavity; on posterior of body.

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Spinal Cavity

answer

Spinal cord; dorsal cavity; on posterior of body.

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Thoracic Cavity

answer

Contains two smaller cavities: pleural and mediastinum; ventral cavity; on anterior of body. Pleural: space surrounding each lung. Mediastinum: contains heart, aorta, trachea, etc.

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Abdominal Cavity

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Stomach, small & large intestines, spleen, pancreas, liver, and gallbladder; ventral cavity; on anterior of body.

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Pelvic Cavity

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Rectum, urinary bladder, urethra, ureters; uterus and vagina in females. Ventral cavity; on anterior of body.

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Abdominal and Pelvic Cavities

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There is nothing separating these two cavities. Often referred to as the abdominopelvic cavity.

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Thoracic and Abdominal Cavities

answer

The diaphragm separates these two cavities.

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Planes of the Body

answer

Dividing the body into planes or flat surfaces is an additional way to describe the body. (useful in CT scans, MRI, etc.) Sagittal Plane, Midsagittal plane, Frontal plane, Transverse Plane

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Sagittal Planes

answer

Vertical planes that separate the sides from each other.

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Midsagittal Plane

answer

Separates the body into right and left halves.

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Frontal Plane

answer

Divides the body into front and back portions.

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Transverse Plane

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Divides the body horizontally into an upper and lower part.

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Positional and Directional Terms

answer

1. Anterior (ventral): Front surface of the body. 2. Posterior (dorsal): Back side of the body 3. Deep: Away from the surface 4. Proximal: Near the point of attachment to the the trunk or near the beginning of a structure. 5. Distal: Far from the point of attachment to the trunk or far from the beginning of a structure. 6. Inferior: Below another structure 7. Superior: Above another structure 8. Medial: Middle or near medial plane of the body 9. Lateral: Pertaining to the side 10. Supine: Lying on the back 11. Prone: Lying on the abdomen.

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Musculoskeletal System

answer

Includes bones, muscles, and joints. Bones are connected to one another by ligaments (fibrous bands on tissue). Muscles are attached to bone by tendons. Acts as a framework for the organs, protects many organs, and provides the ability to move.

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Bones

answer

Complete organs made up of osseous, a connective tissue. Inner core is comprised of heatopoietic tissue (where red blood marrow manufactures blood cells).

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Types of Bones

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Categorized as belonging to either the axial skeleton or the appendicular skeleton. Axial, appendicular, long bones, short bones, flat bones, sesamoid bones.

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Axial Bones

answer

Skull, rib cage, and spine

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Appendicular Bones

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Shoulder, collar bone, pelvic, arms, and legs.

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Long Bones

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Very strong, broad at the ends, and large surfaces for muscle attachment ie: humerus and femur.

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Short Bones

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Small with irregular shapes. Found in wrist and ankle.

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Flat Bones

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Covering soft body parts. Shoulder blades, ribs, and pelvic bones.

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Sesamoid Bones

answer

Small, rounded bones found near joints. Increase efficiency of muscles near a joint. ie: knee cap.

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Axial Skeleton

answer

Skull, spine, rib cage. Skull is made up of two parts, the cranium and facial bones.

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Cranial Bones

answer

1. Frontal Bone: forms the anterior part of skull and forehead. 2. Parietal bones: forms the sides of the cranium. 3. Occipital Bone: forms the back of the skull. Large hole @ ventral surface (foramen magnum) which allows the brain communication with the spinal cord. 4. Temporal Bone: forms the two lower sides of the cranium. 5. Ethmoid Bone: forms the roof of the nasal cavity. 6. Sphenoid Bone: anterior to the temporal bones.

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Facial Bones

answer

1. Zygoma: cheekbone. 2. Lacrimal Bones: paired bones at the corner of the eyes that cradle tear ducts. 3. Maxilla: upper jaw bone. 4. Mandible: lower jaw bone. 5. Vomer: bone that forms the posterior/inferior part of nasal septal wall between nostrils. 6. Palatine Bones: make up part of the roof of the mouth. 7. Inferior Nasal Conchae: make up part of the interior of the nose.

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Spinal/Vertebral Column

answer

Divided into 5 regions from neck to tailbone. 26 bones in spine called vertebrae. Cervical, Thoracic, Lumbar, Sacral, Coccygeal.

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Cervical

answer

Neck bones

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Thoracic

answer

Upper back

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Lumbar

answer

Lower back

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Sacral

answer

Sacrum

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Coccygeal

answer

Coccyx (tailbone)

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Rib Cage

answer

12 pairs of ribs. First 7 pairs join the sternum anteriorly trough cartilaginous attachments called costal cartilages.

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True Ribs

answer

#1-7. Attach directly to the sternum in the front of the body.

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False Ribs

answer

#8-10. Are attached to the sternum by cartilage.

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Floating Ribs

answer

#11 & 12. Not attached at all.

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Appendicular Skeleton: Upper Appendicular Skeleton

answer

Includes shoulder girdle which is made up of the scapula, clavicle, and upper extremities.

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Scapula

answer

Shoulder blade; flat bone that helps support the arm.

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Clavicle

answer

Collarbone; curved horizontal bones that attach to the upper sternum at one end. Helps stabilize the shoulder.

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Upper Extremities

answer

1. Humerus: Upper arm bone 2. Ulna: Lower medial arm bone 3. Radius: Lateral lower arm bone (in line w/ thumb) 4. Carpals: Wrist bones. 2 rows of 4 bones in each wrist. 5. Metacarpals: Five radiating bones in the fingers; the bones the in the palm. 6. Phalanges: Finger bones. Each finger has 3 phalanges except the thumb. 3 phalanges: proximal, middle, distal phalanx. Thumb has a proximal and a distal phalanx.

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Lower Appendicular

answer

Divided into the pelvis and the lower extremities. Pelvis, Ischium, and Pubic Bone.

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Pelvis

answer

Superior and widest bone

question

Ischium

answer

Lower portion of the pelvic bone

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Pubic Bone

answer

Lower anterior part of the bone.

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Lower Extremities

answer

1. Femur: thighbone 2. Patella: knee cap 3. Tibia: Shin 4. Fibula: Smaller, lateral leg bone 5. Malleolus: ankle 6. Tarsal: hind foot bone 7. Metatarsal: midfoot bone 8. Phalanx: toe bones, 14 total (2 in large toe, 3 in each other toes)

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Joints

answer

Parts of the body where 2 or more bones of the skeleton join. Different joints have different ROM (range of movement) ranging from no movement to full ROM.

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No ROM

answer

Most synarthroses are immovable joints held together by fibrous tissue.

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Limited ROM

answer

Amphiathroses are joints joined together by cartilage that is slightly moveable, such as the vertebrae of the spine, or the pubic bone.

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Full ROM

answer

Diathroses are joints that have free movement. Ball-and-socket joints (hip) and hinge joints (knee) are common diathroses joints (synovial joints)

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Synovial Joints

answer

Free moving joints that are surrounded by joint capsules. many have bursae (sacs of fluid) that are located between the bones of the joint and the tendons that hold the muscles in place.

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Muscles

answer

Muscles are tissues composed of cells. Have the ability to contact and relax. Has 3 functions. 1. Allow skeleton the move 2. Responsible for movement of organs 3. Pump blood to circulatory system

question

Tendons

answer

Strong fibrous bands of connective tissue that attach muscles to bones.

question

Muscle Actions

answer

1. Extension: to increase the angle of the joint 2. Flexion: to decrease the angle of a joint 3. Abduction: movement away from the midline 4. Adduction: movement towards the midline 5. Supination: turning the palm or foot upward 6. Pronation: turning the palm or foot downward 7. Dorisflexion: raising the foot, pulling toes toward the shin 8. Plantar flexion: lowering the foot, pointing tows away from shin 9. Eversion: turning outward 10. Inversion: turning inward 11. Protraction: moving a part of the body forward 12. Retraction: moving a part of the body backward 13. Rotation: revolving a bone around its axis.

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Fractures

answer

Broken bone; most occur as a result of trauma; some diseases like cancer or osteoporosis can also cause spontaneous fractures; classified as simple or compound.

question

Simple Fracture

answer

Does not rupture the skin

question

Compound Fracture

answer

Punctures the skin

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Types of Fractures

answer

1. Comminuted: the bone is crushed and/or shattered. 2. Compression: the fractured area of the bone collapses on itself. 3. Colles: the break of the distal end of the radius at the epiphysis often occurs when the patient has attempted to break his/her fall. 4. Complicated: the bone is broken and pierces an internal organ. 5. Impacted: the bone is broken and the ends are driven into each other. 6. Hairline: a minor fracture appears as a thin line on an x-ray and may not extend completely through the bone. 7. Greenstick: the bone is partially bent and partially broken; common in children because the bones are still soft. 8. Pathologic: any fracture occurring spontaneously as a result of disease. 9. Salter-Harris: a fracture of the epiphyseal plate in children. 10. Sprain: traumatic injury to a joint involving the soft tissue. Includes muscles, tendons, and ligaments. Usually as a result of overuse or overstretching.

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Integumentary System

answer

The skin and its accessory organs make up the integumentary system. The skin covers an area of 22 sq. ft. on an average adult. Complex system of specialized tissues containing glands, nerves, and blood vessels. main function is to protect the deeper tissues from excessive loss of minerals, heat, & water. Protects body from diseases by providing a barrier. Largest organ in the body.

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Sebaceous (oil) Glands and Sudoriferous (sweat) glands

answer

Produce secretions that allow the body to be cooled or moisturized. nerve fibers help the body to adjust to the environment by sensory messages relayed to the brain & spinal cord. Also help blood vessels to dilate & sweat glands to produce sweat.

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Epidermis, Dermis, & Subcutaneous Layer

answer

The 3 layers of the skin.

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Epidermis

answer

Thin, cellular membrane layer that contains keratin

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Dermis

answer

Dense, fibrous connective tissue that contains collagen

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Subcutaneous Layer

answer

Thick, fatty tissue

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Hair, Nails, and Glands: Hair Fibers

answer

Composed of tightly fused meshwork of cells filled with hard protein called keratin

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Hair Follicles

answer

The hair has its roots in the dermis & together with their coverings, is hair follicles. Main function of hair is to assist in the regulation of body temp. It holds in heat by standing on end and holding a layer of air as insulation

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Nails

answer

Cover and protect the dorsal surfaces of the distal bones of the fingers and toes

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Nail Body

answer

The part of the nail that is visible

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Nail Root

answer

Under the skin at the base of the nail

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Nail Bed

answer

Vascular tissue under the nail that appears pink when blood is oxygenated and blue/purple when it is oxygen deficient.

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Lunula

answer

The moon-like white area at the base of the nail

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Eponychium

answer

The cuticle of the nail

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Sebaceous Glands

answer

Located in the dermal layer of the skin over the entire body, except for the palms of the hand, and soles of the feet. Secretes and oily substance called sebum.

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Sebum

answer

Oily substance that contains lipids that help lubricate the skin and minimize water loss

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Sweat Glands

answer

Tiny, coiled glands found on almost all body surfaces. Most numerous in palms and soles of feet. Coiled sweat glands originate in the dermis and straighten out to extend up through the epidermis. Two types: eccrine and apocrine sweat glands.

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Pore

answer

The tiny opening on the surface of the skin

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Eccrine Sweat Glands

answer

Secreting glands; far more numerous and are abundant on palms, soles of feet and forehead. Each is a simple, coiled, tubular gland. Ducts connect to pores. Sweat: 99% water, NaCl, vitamin C, antibodies, dermcidin, metabolic wastes.

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Apocrine Sweat Glands

answer

Located mainly in skin of axilla, groin, areolae, and bearded facial regions of adult males, open at hair follicles this sweat is secreted during emotional stress or sexual excitement called "cold sweat"

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Integumentary Vocabulary

answer

1. Albino: deficient in melanin (pigment) 2. Collagen: Structural protein found in the skin and connective tissue 3. Melanin: Major skin pigment 4. Lipoctye: Fat Cell 5. Macule: discolored, flat lesion, freckles, tattoo marks 6. Polyp: benign growth extending from the surface of the mucous membrane. 7. Fissure: groove or crack-like sore 8. Nodule: solid, round or oval elevated lesion more than 1 cm. in diameter 9. Ulcer: Open sore on the skin or mucous membranes 10. Vesicle: small collection of clear fluid; blister 11. Wheal: smooth, slightly elevated edematous (swollen) area that is redder/paler than the surrounding skin 12. Alopecia: baldness 13. Gangrene: death of tissue associated with loss of blood supply 14. Impetigo: bacterial inflammatory skin disease characterized by lesion, pustules, and vesicles

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Common Medical Record Abbreviations

answer

ALL: allergy BM: bowel movement bx, bi: biopsy CA: cancer CC or cc: chief complaint CNS: central nervous system CXR: chest x-ray DNR: do not resuscitate Dx: diagnosis ENT: ears, nose, throat Ex, CPX, PE: exam, examination FH: family history f/u: follow-up GI: gastrointestinal HPI: history of present illness Hx: history N/O: no complaints PERRLA: pupils equal/round/reactive to light PH: past history PT: physical therapy Px: prognosis R: respiration ROM: range of movement ROS: review of systems Rx, Tx: treatment, prescription SH: social history SOB: short of breath Sx: symptoms UA: urinalysis VS: vital signs WNL: within normal limits w/o: without

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Telephone Message

answer

-Name of person whom the call is for -Date and time of call -Name of individual calling -Caller's phone number they wish to be reached at -Detailed reason for call, if caller wishes to leave reason -Action required (call back, Rx refill, etc.) -Initials of person taking the message

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Size of General Business Correspondence Paper

answer

8.5" x 11"

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Business Envelope

answer

No. 10

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E-mail

answer

If patient-related, remains confidential, hard copy placed in patient chart.

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Contents of Medical Record

answer

-Personal Demographics -Medical History -Progress Notes -Encounter forms/superbills -Radiology Reports -Laboratory Reports -Consultations -Med Sheet including allergies -Hospital Discharge Summaries -Consent and disclosure forms -Insurance authorizations and referrals

question

Making a Handwritten Correction in the Medical Record

answer

-Draw a line through the error -Write "error" or "corr." and initial in margin including date and time -Insert the correct immediately after the error -Never use white out, black marker, or eraser on errors -Do not hide errors, bring to the attention of provider if it could affect patient's health and well-being

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Record Maintenance

answer

-Always verify correct medical chart has been pulled - Mend chart as necessary -File documentation in a timely manner -Make sure required forms are kept up to date -Verify patient information periodically

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Retention of Records

answer

-Laws regarding retention vary from state to state -10 years or length of time on statute of limitations -Minors: 3 years after age of majority -Medicare/Medicaid patient: a minimum of 6 years -Deceased patient: 2 years

question

Classification of Records

answer

-Active: Currently receiving treatment -Inactive: Not seen for 6 months -Closed: Moved, terminated, or deceased

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Types of Files

answer

-Drawer files -Shelf files -Rotary circular files -Lateral files -Compactable files -Automated files

question

Filing Supplies

answer

-Chart covers or folders -Labels: color coded, alpha and numeric -OUTguides -Special notation labels: allergies, same name, copays, primary care physician

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Filing Procedures

answer

-Conditioning -Releasing -Indexing and Coding -Sorting -Storing and Filing

question

Conditioning Files

answer

-Mending damaged records -Removing pins, paper clips, brads, staples -Stapling related papers together

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Releasing Files

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Indication that the record is ready to be filed -Signature -Initials -Date -Stamp

question

Indexing and Coding Files

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-Deciding where document is to be filed -Underline name or subject of how it is to be filed -Every paper in patient's chart should have a name and date

question

Sorting Files

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Arranging papers in a filing sequence -Alphabetical -Numeric -Days of the week -Days in the month -Months of the year

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Storing and Filing Files

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-Inserted face up -Most recent date on top -Document completely in file

question

Locating Misplaced Files

answer

Missing Document Only -In the folder in front of or behind the correct folder -Between folders -Under the files -Patient with a similar name Entire medical record -Physician's desk -Billing department -Nursing station -Office manager

question

12 Rules of Indexing (some repeat from earlier study cards)

answer

1. Last names are considered first, then first name second. 2. Nothing comes before something -Smith, T. -Smith, Thomas 3. Hyphenated names are considered one unit 4. The apostrophe is disregarded 5. When a determination of order cannot be made, index in the order the name is written. -Chang Liu 6. Names with prefixes are considered part of the name -Von Hagen 7. Abbreviated names are filed as written 8. Mac and Mc are filed in alphabetical order 9. Married women are indexed by their legal name 10. Titles are not used as filing units 11. Terms of seniority, profession or academic degree are only used to distinguish same names 12. Articles (The and A) are disregarded when indexing

question

Which block is the physician's signature located in?

answer

Block #31

question

OCR (Office of Civil Rights)

answer

Federal government division that enforces the privacy standards

question

How many provisions does HIPPA contain?

answer

Two

question

Sentinel Event

answer

An unexpected occurrence involving death, or serious physical or psychological injury or the risk thereof. ie: mistaken identity of a patient

question

Subjective Information

answer

Information that is documented in the medical record that is from answers obtained by asking questions from the patient ie: patient's family history

question

How many diagnoses can the CMS-1500 form have?

answer

Four

question

Why is it usually poor policy to accept third-party checks from patients?

answer

You cannot verify the reliability of the maker

question

JCAHO (Joint Commission)

answer

The non-profit organization that assists healthcare facilities by providing accreditation

question

Audit

answer

The process done before claims submission to examine claims for accuracy and completeness

question

Medicare Part D

answer

Drug services

question

Legal owner of the patient's medical record

answer

The physician or agency where services were provided. "The Maker" of the record.

question

TRICARE

answer

Health insurance designed for military dependents and retired personel

question

PHI stands for

answer

Protected Health Information

question

Hard Copy

answer

A claim that is printed and mailed to the carrier

question

Healthcare Information is used to

answer

-Determine how many patients enter a facility with the same diagnosis -Decide what equipment is needed to meet the needs of the patient population -Help the facility plan for the needs of next week and next year

question

Medicaid

answer

The federal and state-sponsored health insurance program for the medically indigent

question

Worker's Compensation

answer

A type of insurance that protects workers from loss wages after an industrial accident that happened on the job

question

Professional Courtesy

answer

Charging reduced or no-fee for services rendered to other medical professionals

question

Assets

answer

The properties owned by a business

question

Medicare Part B

answer

Physician office visits

question

Accounting

answer

A system of recording, classifying, and summarizing financial transactions

question

Blanket-position bonding

answer

Covers all employees in a facility

question

Patient privacy complaints

answer

Patients have 180 days from the time the patient knew the act occurred to file a complaint

question

Common appointment book abbreviations

answer

CPE/CPF: complete physical exam NP/New Pat: new patient NS: no show Px: physical OV: office visit FU: follow up ReC: recheck Ref: referral Can: cancelled N&V: nausea & vomitting Pgt: pregnancy test RS: reschedule

question

Common time slots for appointments

answer

Physical: 1 hour School Physical: 30 minutes Recheck: 15 minutes Dressing Change: 10 minutes BP Check: 5 minutes Patient Teaching: 30 minutes-1 hour

question

What must a letter of withdrawal of care state?

answer

-That professional care is being discontinued. -The physician will provide copies of the patient's records to new physician -The patient should seek new care provider as soon as possible

question

How should a letter of withdrawal be mailed?

answer

Certified

question

US Supreme Court

answer

The ultimate appellate court in the United States

question

Ways to increase appointment show rates

answer

automated call reminders appointment cards conformation calls email reminders mailed reminders

question

Medical Term for a Stroke

answer

Cardiovascular Accident

question

Suspected Diagnosis

answer

a diagnosis that is questionable, probable, or likely

question

E codes

answer

codes that describe the circumstances of an accident or injury

question

Where should you begin the search for a code?

answer

Alphabetic index

question

Etiology

answer

The cause of a disorder

question

Manifestation

answer

The signs and symptoms of a disease

question

ICD-9 Codes

answer

Consist of 3 primary digits, and up to 2 additional digits.

question

Benign

answer

A non-malignant cancerous growth

question

CBMR

answer

Computer-based medical record

question

Shingling

answer

The method of filing in which one report is laid on top of older reports

question

V Codes

answer

(V01-V82) are the codes that refer to factors that influence the health status of a patient. A definite diagnosis cannot be stated, but a valid reason for seeing the provider exists. (ie: well baby check up, annual p.e.)

question

Continuity of Care

answer

Continuation of care smoothly from one provider to another, so the patient receives the most benefit and no interruption in care.

question

CC (Chief Complaint)

answer

-Nature and duration of pain, if any -When symptoms were first noticed by patient -Patient's opinion of causes of problem -Remedies patient may have applied -Patient has had same/similar condition in the past -Other treatment received for condition in the past

question

Differential Diagnosis

answer

The process of weighing the probability of one disease causing the patient's illness against the probability that other diseases are causative

question

CHEDDAR

answer

C- Chief Complaint H- History E- Examination D- Details (of problem and complaint) D- Drugs & dosages A- Assessment R- Return visit information, if applicable

question

Medicine and Law: Act

answer

The formal action of a legislative body; a decision or determination of a sovereign state; a legislative council or a court of justice

question

Allegation

answer

A statement by a party to a legal action of what the party undertakes to prove; an assertion made without proof

question

Nosocomial Infection

answer

hospital-acquired infection

question

NCHS (National Center for Health Statistics)

answer

Collects data from birth and death records, medical records, interview surveys. Health statistics agency; mission: provide statistical information that guides actions and policies to improve the health of American people

question

Clustering

answer

Patients with similar problems are booked consecutively. A block of time is set aside for particular types of cases.

question

Underuse of Medical Care

answer

When Doctors or hospitals neglect to give patients medically necessary care or to follow proven health care practices

question

Misuse of Medical Care

answer

Medical errors; when patient doesn't fully benefit from a treatment because of a preventable problem- or when the patient is harmed by a treatment

question

Overuse of Medical Care

answer

Occurs when a drug or treatment is given without medical justification

question

HITECH Act

answer

Health Information Technology for Economic and Clinical Health Act

question

Purpose of HITECH Act

answer

Designed to increase safeguards that will protect the privacy of a patient's PHI from being compromised

question

OUTfolder

answer

A folder used to provide space for the temporary filing of materials

question

OUTguide

answer

A heavy guide used to replace a folder temporarily removed from the filing space

question

How does OSHA regulate and enforce safety and health in the workplace?

answer

By setting safety standards

question

Addendum

answer

An error discovered at a later date. (Corrected in the same manner as a real-time error)

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