CMAA Study Guide – Flashcards
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What is the medical law?
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the medical administrative assistant is required to have a basic understanding of the legal principles.
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what is the physician-patient relationship?
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an implied contract in which the physician is expected to assess and treat the patient with the same amount of knowledge, skill, judgment as another physician under the same circumstamces
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define: implied consent
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apperent through their action of seeking the services of the physician
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define: informed consent
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a written form that states the understanding of the prescribed treatment as well as its accompanying risks
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define: Good Samaritan Act
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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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What does the patient bill of right do?
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it promotes the interests and well beings of patients within any healthcare facility
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What is HIPPA?
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[Health Insurance Portability and Accountability Act] a fediral law designed to protect the privacy of individuals health information
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define: Abandonment
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the discontinuation of medical care without proper notice
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define: Arbitration
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the usage of an impartial third party for the hearing and determination of a dispute
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define: Battery
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the unlawful use of force or violence
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define: Negligence
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the failure to provide the necessary care that is required for a person's situation
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define: Statutes
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state law
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phone etiquette STEP 1:
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answer the phne promptly and kindly
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phone etiquette STEP 2:
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be sure to properly speak into the phne
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phone etiquette STEP 3:
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be sure to give the caller ur undivided attn
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phone etiquette STEP 4:
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speak clearly and distinctly
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phone etiquette STEP 5:
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always be courteous
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phone etiquette STEP 6:
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be sure to ask the caller's permission be4 placing them on hold
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phone etiquette STEP 7:
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never allow and angry or aggressive caller upset u; remain calm and composed
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what is verbal communication?
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the use of language or words spoken
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what is nonverbal commuication?
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the use of eye contact, body language, facial expression, or symbolic expression to communicate a message.
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What types of scheduling is there?
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wave scheduling, modified wave scheduling, double booking
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define: Wave Scheduling
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provides service to several patients at same time
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define: Modified Wave Scheduling
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small groups of patients are scheduled at intervals throughout the hour
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define: Double Booking
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scheduling two patients to see the physician at the same time
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Scheduling a new patient: STEP 1
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obtain and verify general information
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Scheduling a new patient: STEP 2
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gather appropriate information regarding a patient referral
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Scheduling a new patient: STEP 3
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determine the patient's chief complaint
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Scheduling a new patient: STEP 4
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make the patient aware of the various dates and times they are available to come in
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define: Express Mail
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available everyday of the year, including holidays, for items up to 70lbs in weight and 108 inches in height
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define: First-Class Mail
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includes letters, postal cards, postcards, and business reply mail
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define: Priority Mail
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first-class mail that weighs more than 13 oz
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define: Certified Mail
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gives the sender the option to recieve proof of delivery
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define: Bulk Mailing
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a form of mailing large volumes of information which is presorted by zipcode
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what are the types of health insurences?
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Indivisual Policies, Group Policies, Government Plans
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define: Indivisual Policies
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ppl with this type of insurance are usually ineligible to recieve benefits from a gvrnmnt plan. this type of coverage ir characterized by high premiums and a limited amount of benefits.
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define: Group Policies
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provides coverage for employees under a single contract. this type of coverage is characterized by greater benefits and low premiums
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define: Government Plans
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available to a large group of ppl who meet specific
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define: Assignment of Benefits
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an arrangement by which a patient requests that their health benefit payments be made directly to a physician
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define: Benefit
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the amount payable by the carrier toward the cost of services for which the patient is eligible for
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define: Deductible
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the amount an indivisual must pay for health care expenses before insurance (or self insured company) covers the cost.
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define: Copayment
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the portion of a service fee that the patient must pay
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define: Policy
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a document that describes the insurance coverage for an indivisual or property
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define: Premium
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the amount the patient pays for an insurance contract
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define: 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, reccomended by a doctor, or required for treatment
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define: Waiting Period
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a period of time when you are not covered by insurance for a particular problem
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how many steps are there to establish a patients medical record?
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6
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STEP 1 to Establish a medical record
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determine the patients status in the office (New or Established)
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STEP 2 to Establish a medical record
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obtain the required general information
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STEP 3 to Establish a medical record
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enter the information into the patient history form
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STEP 4 to Establish a medical record
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review the form for accuracy
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STEP 5 to Establish a medical record
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enter the patients name into the computerized ledger
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STEP 6 to Establish a medical record
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assemble the appropriate forms, prepare the folder and file as necessary
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what are the components of the medical record?
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Personal and Medical History, Patients family history, patients social history, patients chief complaint, diagnosis.
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define: Personal and Medical History
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created using information gathered fromthe patient. usually includes information such as past illnesses, surgical operations, and the patients daily health habits
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define: Patients Family History
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includes information regarding the health of members of the patients family, and a record of the cause of death.
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define: Patients Social History
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includes the information regarding the patients lifestyle
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define: Patients Chief Complaint
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A statement of the patients symptoms
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define: Diagnosis
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A decision made based on the information regarding the patients history and the results of the doctors examination.
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what is the SOAP approach?
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a format for progress notes based on the letters od the word
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what is "S" in SOAP?
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Subjective Impressions
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what is "O" in SOAP?
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Objective clinical evidence
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what is "A" in SOAP?
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Assesment or Diagnosis
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what is "P" in SOAP?
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Plans for further studies, treatment, or management
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FILING- how many indexing rules are there?
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5
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INDEXING RULE 1:
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Last name, first name, middle name/initial
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INDEXING RULE 2:
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the hyphenated portion of a name is used as 1 unit ex. anna smith-meyer is filed as smithmeyer, anna
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INDEXING RULE 3:
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Apostrophes are not used in filing
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INDEXING RULE 4:
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titles, and terms of seniority are only used to distinguish from an identical name
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INDEXING RULE 5:
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when indexing a company, articles such as "the" and "a" are not used
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ALPHABETICAL FILING
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folders are arranged in the same sequence as the alphabet
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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 number, records are filed backwards in groups.
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Bi/o
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Life
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carcin/o
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cancerous, cancer
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cephal/o
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cerebrum (largest part of the brain)
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how many body systems are there?
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11
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BODY SYSTEM # 1 musculoskeletal
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FUNCTION: support, movement protection ORGAN: muscles, bones, joints, bone marrow
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BODY SYSTEM # 2 Integumentary
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FUNCTION: protection ORGAN: skin, hair, nails
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BODY SYSTEM # 3 Gastrointestinal
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FUNCTION: nutrition ORGAN: stomach, intestines
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BODY SYSTEM # 4 Urinary
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FUNCTION: elimination of nitrogenous waste ORGAN: kidneys, bladder, ureters, urethra
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BODY SYSTEM # 5 Reproductive
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FUNCTION: reproduction ORGAN: ovaries, testes
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BODY SYSTEM # 6 Blood/Lymphatic
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FUNCTION: transportation ORGAN: blood cells
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BODY SYSTEM # 7 Immune
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FUNCTION: protectionl ORGANS: lymph glands
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BODY SYSTEM # 8 Cardiovascular
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FUNCTION: transportation ORGAN: heart, vessels
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BODY SYSTEM # 9 Respitory
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FUNCTION: delivers oxygen to cells, removes carbon dioxide ORGAN: lungs, bronchi, trachea
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BODY SYSTEM # 10 Nervous/Behavioral
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FUNCTION: recieve/process information ORGAN: brain, nerves, mind
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BODY SYSTEM # 11 Endocrine
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FUNCTION: effects changes through chemical messengers ORGAN: pancreas, thyroid
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Anterior (ventral)
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front surface of the body
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Posterior (dorsal)
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back side of the body
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deep
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away from the surface
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Inferior
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below
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proximal
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near
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distal
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far
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Superior
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above another structure
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Medial
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pertaining to the middle of the body
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lateral
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side
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Supine
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lying on the back
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Prone
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lying on belly
