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.
-Patient is provided with a copy on first visit, or it is visibly posted within the facility.
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.
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.
Nonverbal: Eye contact, body language, facial expressions, symbolic expressions.
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.
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.
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.
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.
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.
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.
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.
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.
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
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
Organs: muscles, bones, joints, bone marrow.
Organs: skin, hair, nails
Organs: stomach, intestines
Organs: kidneys, bladder, ureters, urethra
Organs: ovaries, testes
Organs: blood cells
Organs: lymph glands
Organs: heart, vessels
Organs: lungs, bronchi, trachea.
Organs: brain, nerves, mind
Organs: pancreas, thyroid
Cranial, Spinal, Thoracic, Abdominal, Pelvic
Pleural: space surrounding each lung.
Mediastinum: contains heart, aorta, trachea, etc.
Sagittal Plane, Midsagittal plane, Frontal plane, Transverse Plane
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.
Skull is made up of two parts, the cranium and facial bones.
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.
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.
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.
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)
1. Allow skeleton the move
2. Responsible for movement of organs
3. Pump blood to circulatory system
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.
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.
this sweat is secreted during emotional stress or sexual excitement called “cold sweat”
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
BM: bowel movement
bx, bi: biopsy
CC or cc: chief complaint
CNS: central nervous system
CXR: chest x-ray
DNR: do not resuscitate
ENT: ears, nose, throat
Ex, CPX, PE: exam, examination
FH: family history
HPI: history of present illness
N/O: no complaints
PERRLA: pupils equal/round/reactive to light
PH: past history
PT: physical therapy
ROM: range of movement
ROS: review of systems
Rx, Tx: treatment, prescription
SH: social history
SOB: short of breath
VS: vital signs
WNL: within normal limits
-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
-Med Sheet including allergies
-Hospital Discharge Summaries
-Consent and disclosure forms
-Insurance authorizations and referrals
-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
– Mend chart as necessary
-File documentation in a timely manner
-Make sure required forms are kept up to date
-Verify patient information periodically
-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
-Inactive: Not seen for 6 months
-Closed: Moved, terminated, or deceased
-Rotary circular files
-Labels: color coded, alpha and numeric
-Special notation labels: allergies, same name, copays, primary care physician
-Indexing and Coding
-Storing and Filing
-Removing pins, paper clips, brads, staples
-Stapling related papers together
-Underline name or subject of how it is to be filed
-Every paper in patient’s chart should have a name and date
-Days of the week
-Days in the month
-Months of the year
-Most recent date on top
-Document completely in file
-In the folder in front of or behind the correct folder
-Under the files
-Patient with a similar name
Entire medical record
2. Nothing comes before something
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.
6. Names with prefixes are considered part of the name
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
-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
NP/New Pat: new patient
NS: no show
OV: office visit
FU: follow up
N&V: nausea & vomitting
Pgt: pregnancy test
School Physical: 30 minutes
Recheck: 15 minutes
Dressing Change: 10 minutes
BP Check: 5 minutes
Patient Teaching: 30 minutes-1 hour
-The physician will provide copies of the patient’s records to new physician
-The patient should seek new care provider as soon as possible
-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
D- Details (of problem and complaint)
D- Drugs & dosages
R- Return visit information, if applicable