Certified Medical Administrative Assistant

Medical Assistant Duties & Responsibilities
Telephone coverage, scheduling, maintenance of medical records, management of all correspondences

Qualities of a Medical Assistant
Dependability, courtesy, initiative, interpersonal skills

Medical Profession Liability
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.

Rules that must be followed under physician-patient relationship
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.

Consent To Treat
Once the physician-patient relationship has been entered, the physician must have consent to treat the patient. In most cases,

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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.

Good Samaritan Act
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.

Patient’s Bill of Rights
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.

HIPPA Patient Privacy Rule
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).

Vocabulary
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.

Phone Etiquette: Steps to ensure proper phone etiquette
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.

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

Appointments: Considerations when selecting an appointment book
Size in consideration of desk space available, accommodation of # of appointments made, comfort for writing, space for details necessary.

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

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

Modified Wave
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)

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

Scheduling New Patients
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.

Scheduling Conflicts
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.

Types of Mail
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.

Health Insurance: Verification of Insurance Benefits
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.

Types of Health Insurance
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.

Insurance Terms
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.

Usual, Customary, and Reasonable (UCR) or Covered Expenses
An amount customarily charged for or covered for similar services and supplies which are medically necessary, recommended by a doctor, or required for treatment.

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

Medical Records Management: Creating a Medical Record
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.

Components of the Medical Record
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.

SOAP approach to documenting
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

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

POMR record organization
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.

Filing: Indexing Rules
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

Alphabetical Filing
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.

Numerical Filing
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.

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

Tickler File
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.

Medical Terminology
Combining forms, prefixes, and suffixes

Arthr/o
joint

Bi/o
Life

Cardi/o
heart

Carcin/o
cancerous

Cephal/o
head

Cerebr/o
cerebrum

Cyt/o
cell

Denti/o
teeth

Derm/o
skin

Electr/o
electrical activity

Enter/o
intestines

Fet/o
fetus

Gastr/o
stomach

Hepat/o
liver

Iatr/o
treatment, physician

Leuk/o
white

Nephr/o
kidney

Oste/o
bone

Path/o
disease

Ren/o
kidney

Rhin/o
nose

Sarc/o
flesh

Thromb/o
clotting

Ur/o
urinary tract

-al
pertaining to

-algia
pain

-dynia
pain

-ectomy
excision, removal

-emia
blood condition

-genic
produced by/ pertaining to producing

-globin
protein

-itis
inflammation of

-oma
tumor

-osis
condition, usually abnormal

-pathy
disease condition

-sis
state of; condition

-ectomy
removal of

-graphy
process of recording

-metry
process of measurement

-scopy
a visual examination

-stomy
a new opening

-tomy
incision

-tripsy
process of crushing

-graph
instrument for recoring

-meter
instrument to measure

-scope
instrument to visually or aurally examine

-tome
instrument to cut

-tripter
instrument to crush

-trite
instrument to crush

Ante-
before, in front of

Anti-
against

Brady-
slow

Dia-
through, complete

End-, Endo-
within

Epi-
above, upon

Hyper-
excessive, above

Hypo-
deficient, below

Peri-
around, surrounding

Pre-
before

Sub-
below, under

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

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

Integumentary System
Functions: protection
Organs: skin, hair, nails

Gastrointestinal System
Functions: nutrition
Organs: stomach, intestines

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

Reproductive System
Functions: reproduction
Organs: ovaries, testes

Blood/Lymphatic System
Functions: transportation
Organs: blood cells

Immune System
Functions:protection
Organs: lymph glands

Cardiovascular System
Functions: transportation
Organs: heart, vessels

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

Nervous/Behavioral System
Functions: receive/process information
Organs: brain, nerves, mind

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

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

Cranial Cavity
Brain; dorsal cavity; on posterior of body.

Spinal Cavity
Spinal cord; dorsal cavity; on posterior of body.

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

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

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

Abdominal and Pelvic Cavities
There is nothing separating these two cavities. Often referred to as the abdominopelvic cavity.

Thoracic and Abdominal Cavities
The diaphragm separates these two cavities.

Planes of the Body
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

Sagittal Planes
Vertical planes that separate the sides from each other.

Midsagittal Plane
Separates the body into right and left halves.

Frontal Plane
Divides the body into front and back portions.

Transverse Plane
Divides the body horizontally into an upper and lower part.

Positional and Directional Terms
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.

Musculoskeletal System
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.

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

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

Axial Bones
Skull, rib cage, and spine

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

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

Short Bones
Small with irregular shapes. Found in wrist and ankle.

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

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

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

Cranial Bones
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.

Facial Bones
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.

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

Cervical
Neck bones

Thoracic
Upper back

Lumbar
Lower back

Sacral
Sacrum

Coccygeal
Coccyx (tailbone)

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

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

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

Floating Ribs
#11 & 12. Not attached at all.

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

Scapula
Shoulder blade; flat bone that helps support the arm.

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

Upper Extremities
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.

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

Pelvis
Superior and widest bone

Ischium
Lower portion of the pelvic bone

Pubic Bone
Lower anterior part of the bone.

Lower Extremities
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)

Joints
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.

No ROM
Most synarthroses are immovable joints held together by fibrous tissue.

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

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

Synovial Joints
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.

Muscles
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

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

Muscle Actions
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.

Fractures
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.

Simple Fracture
Does not rupture the skin

Compound Fracture
Punctures the skin

Types of Fractures
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.

Integumentary System
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.

Sebaceous (oil) Glands and Sudoriferous (sweat) glands
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.

Epidermis, Dermis, & Subcutaneous Layer
The 3 layers of the skin.

Epidermis
Thin, cellular membrane layer that contains keratin

Dermis
Dense, fibrous connective tissue that contains collagen

Subcutaneous Layer
Thick, fatty tissue

Hair, Nails, and Glands: Hair Fibers
Composed of tightly fused meshwork of cells filled with hard protein called keratin

Hair Follicles
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

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

Nail Body
The part of the nail that is visible

Nail Root
Under the skin at the base of the nail

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

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

Eponychium
The cuticle of the nail

Sebaceous Glands
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.

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

Sweat Glands
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.

Pore
The tiny opening on the surface of the skin

Eccrine Sweat Glands
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.

Apocrine Sweat Glands
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”

Integumentary Vocabulary
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

Common Medical Record Abbreviations
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

Telephone Message
-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

Size of General Business Correspondence Paper
8.5″ x 11″

Business Envelope
No. 10

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

Contents of Medical Record
-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

Making a Handwritten Correction in the Medical Record
-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

Record Maintenance
-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

Retention of Records
-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

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

Types of Files
-Drawer files
-Shelf files
-Rotary circular files
-Lateral files
-Compactable files
-Automated files

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

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

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

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

Indexing and Coding Files
-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

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

Storing and Filing Files
-Inserted face up
-Most recent date on top
-Document completely in file

Locating Misplaced Files
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

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

Which block is the physician’s signature located in?
Block #31

OCR (Office of Civil Rights)
Federal government division that enforces the privacy standards

How many provisions does HIPPA contain?
Two

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

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

How many diagnoses can the CMS-1500 form have?
Four

Why is it usually poor policy to accept third-party checks from patients?
You cannot verify the reliability of the maker

JCAHO (Joint Commission)
The non-profit organization that assists healthcare facilities by providing accreditation

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

Medicare Part D
Drug services

Legal owner of the patient’s medical record
The physician or agency where services were provided. “The Maker” of the record.

TRICARE
Health insurance designed for military dependents and retired personel

PHI stands for
Protected Health Information

Hard Copy
A claim that is printed and mailed to the carrier

Healthcare Information is used to
-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

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

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

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

Assets
The properties owned by a business

Medicare Part B
Physician office visits

Accounting
A system of recording, classifying, and summarizing financial transactions

Blanket-position bonding
Covers all employees in a facility

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

Common appointment book abbreviations
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

Common time slots for appointments
Physical: 1 hour
School Physical: 30 minutes
Recheck: 15 minutes
Dressing Change: 10 minutes
BP Check: 5 minutes
Patient Teaching: 30 minutes-1 hour

What must a letter of withdrawal of care state?
-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

How should a letter of withdrawal be mailed?
Certified

US Supreme Court
The ultimate appellate court in the United States

Ways to increase appointment show rates
automated call reminders
appointment cards
conformation calls
email reminders
mailed reminders

Medical Term for a Stroke
Cardiovascular Accident

Suspected Diagnosis
a diagnosis that is questionable, probable, or likely

E codes
codes that describe the circumstances of an accident or injury

Where should you begin the search for a code?
Alphabetic index

Etiology
The cause of a disorder

Manifestation
The signs and symptoms of a disease

ICD-9 Codes
Consist of 3 primary digits, and up to 2 additional digits.

Benign
A non-malignant cancerous growth

CBMR
Computer-based medical record

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

V Codes
(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.)

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

CC (Chief Complaint)
-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

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

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

Medicine and Law: Act
The formal action of a legislative body; a decision or determination of a sovereign state; a legislative council or a court of justice

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

Nosocomial Infection
hospital-acquired infection

NCHS (National Center for Health Statistics)
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

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

Underuse of Medical Care
When Doctors or hospitals neglect to give patients medically necessary care or to follow proven health care practices

Misuse of Medical Care
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

Overuse of Medical Care
Occurs when a drug or treatment is given without medical justification

HITECH Act
Health Information Technology for Economic and Clinical Health Act

Purpose of HITECH Act
Designed to increase safeguards that will protect the privacy of a patient’s PHI from being compromised

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

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

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

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

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