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FBLA Health Care Administration
Chapter 4, Medical Documentation and Electronic Health Record
Terms in this set (1314)
A health record can be defined as written or graphic information documenting facts and events during the rendering of patient care. Either paper or electronic format.
American Recovery and Reinvestment Act of 2009 (ARRA)
encourages implementation by offering five annual financial incentives for qualifying offices that convert to an electronic format beginning in 2011 and ending in 2015 or 2016.
1. Patient registration (demographic information)
2. Medication record
3. history and physical exam, notes or report
4. Progress or chart notes
5. Consultation reports
6. imaging and x-ray reports
7. Laboratory reports
8. Immunization record
9. Consent and authorization forms
10. Operative report
11. Pathology report.
In hospital setting would also include
- attending physician's orders
- date of admission
- hospital stay dates
- discharge date
- discharge summary
Health record content (common)
1. problem-oriented record (POR system)
2. source-oriented record (SOR system or integrated system)
What types of systems are used in electronic health record system (EHR)
Problem-Oriented Record System (POR)
consists of: flow sheets, charts, or graphs, that allow aphysician to quickly locate information and compare eaulation
Source-Oriented Record system (SOR)
documents are arranged according to sections (e.g., H&P section, progress notes, lab tests, radiology reports, or surgical operations) SOR system filed in reverse chronological order. More difficult to locate data due to scattering throughout
Electronic Health Record System
collection of medical information about the past, present and future of a patient that resides in a centralized electronic system.
: An EMR is individual physician's EMR for the patient, including medical history, allergies, and appointment information.
An EHR is all patient medical information from many information systems, including all components of the EMR.
Difference between an EHR and an EMR
1. no physical space required
2. abstracting data is eliminated except when free-form documentation such as narrative notes, dictations, and natural language processing is used.
3. free-text approach, encourages use of abbreviations or fewer spelled out words may result in scant or undecipherable documents.
4. Electronic systems have built in security safeguards to protect against improper disclosure, unauthorized access, or unintended alteration of information for both the data and the system.
5. ARRA requires covered entities to notify individuals if their protected health information is accessed or disclosed in an unauthorized manner.
Advantages of EHR
Systemized Nomenclature of Medicine for Clinical Terminology. Medical terminology cassification system that codes text data in an EHR system will assist in standardizing clinical medical terminology
Medicare Modernization Act
created the Commission on Systemic Interoperability to develop a strategy to make health care information abailable at all times to patients and physicians. Goal by 2014.
Electronic medical report
part of health record that is used to complete the insurance claim form.
permanent legal document that formally states outcomes of the patients' examination or treatment in letter or report form.
- DOS, date of service
- POS, place of service
- Dx, diagnosis
- codes are used for interpretation by the insurance company when processing a claim
all individuals providing health care services that chronlogically record pertinent facts and observations about patient's health.
charting, may be electronically handwritten, dictated and transcribed or downloaded from a (PDA) personal digital assistant or smartphone
speech recognition system
computerized voice recognition system which makes it possible for computer to respond to spoken words
correctionist, proofreads and edits the computer-generated documents
refers to the hospital staff member who is legally responsible for the care and treatment given to a patient
provider whose opinion or advice regarding evaluatio or management of a specific problem is requested by another physician
non-physician practitioner (NPP)
nurse practitioner, clinical nurse specialist, licensed social worker, nurse midwife, physical therapist, speech therapist, audiologist, or physician assistnat who furnishes a consultation or treats a patient for a specific medical problem, pursuant to state law, and who use the results of a diagnostic test in the management of the patient's specific medical problem
individiual in the hospital directing the selection, preparation, or administration of tests, medication, or treatment
primary care physician (PCP)
oversees the care of the patients in a managed health care plan and refers patients to see specialists for services as needed
provider who sends the patient for tests or treatment
physician who has finished medical school and is performing one or more years of training in a specialty area on the job at a hospital (medical center). Residents perform the elements required for an evaluation and management (E/M service in the presence of or, jointly with, the teaching physican, and residents document the service.
doctor who has responsibilities for training and supervising medical students, interns, or residents and who takes them to the bedsides of patients in a teaching hospital to review course and treatment. Teaching physicians must document that they supervised and were physically present at the time during key portions of the service provided to the patient when performed by a resident.
Treating or performing physician
provider who renders a service to a patient. In the Medicare program, the definition of a treating physician is a physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiary's specific medical problem.
Five reasons for legible documention:
If handwritten, entries in patient record must be legible.
a. avoids denied or delayed payments by insurance carriers
b. enforcement of medical record-keeping rules by insurance carriers requiring accurate document that supports procedure and diagnostic codes.
c. Subpoena of health records by state investigators or the court for review.
d. Defense of a professional liabilty claim.
e. Execution of the physician's written instructions by a patient care-giver.
Evaluation and management, occurs in office visit, inpatient hospital facilities, and nursing homes
Current Procedural Terminology
Centers for Medicare and Medicaid Services.
American Medical Association and Centers for Medicare and Medicaid Services.
Developed documentation guidelines for CPT E/M services.
Medicare administrator contractors
also called fiscal intermediaries, fiscal agents, and fiscal carriers, conduct reviews for irregular reporting patterns.
HAVE WALK IN RIGHTS, access to a medical practicde w/o apptment or search warrant.
Third-party payers and federal programs have responsiblity to ensure that professional services provided to patients were medically mecessary
Documentation must support the level of service and each procedure rendered.
criterion used by insurance companies, as well as federal programs, when making decisions to limit or deny payment. Payment may be delayed, downcoded or denied if the medical necessity of a treatment is questioned.
Good medical practice standards
Insurers differ on definition and may not cover services depending on the benefits of the plan.
Advance beneficiary Notice of Noncoverage, also know as waiver of liability agreement or responsibility statement
If provider has submitted insurance claims for payments deemed fraudulent or inappropriate by government.
External Audit Point System
A point system used while reviewing each patient's health record during the performance of an audit. Points award only if documentation is present for elements required in health record. Point system is used to show where deficiencies occur in health record documentation, evaluation and substantiate proper use of diagnostic and procedural codes.l
consequences of accidental (or intentional) miscoding.
HMO, PPO, private carriers can claim refunds
Medicare has power to levy fines and penalties and exclude providers from Medicare program
Insurance carrier and documentation
If it is not documented, then it was not performed. (have right to deny reinbursement)
Medicare carriers frequent audits
prepayment and postpayment audits to monitor accuracy physicians' use of medical services and procedure codes.
Billing Patterns causing possible audits
a. billing intentionally for unnecessary services
b. billing incorrectly for services of physican extenders (NPP)
C. billing for diagnostic tests w/o separate report in health record
d. changing DOS on insurance claims to cmply with policy coverage dates
e. waiving copayments or deductibles, or allowing other illegal discounts
f. ordering excessive diagnostic tests
g. using 2 different provider numbers to bill the same services for same patient
h. failing to return overpayments made by the Medicare program
i. misusing prover ID number
j. using improper modifiers for financial gain
Common Medical Office Documents/
Documentation guidelines for Medical Services
1. The health record should be accurate, complete (detailed), and legible.
2. Documentation of each patient encounter includes or provide reference to following:
a. chief complaint or reason for encounter
b. relevant history
c. physical examination
e. prior diagnostic test results
f. assessment, clinical impression, or diagnosis
g. plan for care
h. date and eligible identity of the health care professional
3. The reason for encounter stated
4. Past and present diagnoses
5. Appropriate health risk factors should be identified
6. The patient's progress, response to and changes to treatment, planned follow-up care and instructions and diagnosis should be documented.
7. Patient refusal to follow medical advise
8. Procedure and diagnostic codes reported on the insurance claim form or billing statement supported by documentation.
9. Confidentiality of health record maintained
10. Each chart entry dated and signed
11. Standardized charting procedures for progress notes. Use either SOAP or CHEDDAR styles or narriative or detailed descriptive style. Must be detailed enough to support current documentation requirements.
12. Treatment plans written and consistent with working dx.
13. medications prescribed and taken, listed
14. request for or need for consultation must be documented. Include: consultant's opinion, services ordered documented, and communicated to requesting physician.- see pg 96 for additional
Four R's: requesting, render, report, reason, (and possibly return"
15. Record patient's fialture to return for needed treatment, in Heath record, appointment book, financial reocrd or ledger, follow telephone call or letter to patient indicated
16. How to correct documentation "errors". see pg 96.
Never delete or or key over incorrect data. or flag it as amended or obsolete and create an addendum typed as a separate document or for a chart note inserted below in the next space availabe. paper charting - initial correction. never erase, white, out or use self adhesive paper over any information record on a patient record.
17. Document all lab tests, physcian intials report as read.
18. Ask physician for approval for differnt code before transmitting claims
19. Retain all records (until positive no longer necessary by conforming to federal and state laws, and physician wishes)
Contents of a Medical Report
Degree of documentation depends on the complexity of the service and the specialty of the physican.
history, examination, medical decision making
Documentation of History
chief complaint (CC), History of Present Illness (HPI), review of systems (ROS), past history, family, or social history (PFSID) extent of each depends on present problems
Chief complaint (CC)
concise statement usually in patient's own words describing symptom, problem, condition, diagnosis, physician-recommended return, or other factor.
REQUIRED FOR ALL LEVELS OF HISTORY:
History of present illness (HPI)
chronological description of development of the patients present illness from first sign or symptom or from previous encounter to present (may include one or more of the following): 1. location, 2, Quality/Character of the symptom/pain, 3. severity or degree (1-10), 4. Duration, 5. Timing, when, 6. Context - situation associated with symptom
7. Modifying factors that make it better or worse, 8. Associated signs and symptoms
Review of Symptoms (ROS)
Inventory of body systems obtained through a series of questions that is used to identify signs or symptoms patient might be experiencing or has experienced. In ROS, trhe body systems are counted and totaled. The health record should describe one system of the ROS for a pertinent to problem level. For a complete level, at least 10 organ systems must be reviewed and documented.
Past History (PH)
Patients past experiences with illnesses, operations, injuries, and treatments
Family History (FH)
A review of medical events in the patient's family including diseases that may be heriditary or place the patient at risk.
Social History (SH)
An age-appropriate review of past and current activities (smoking, alcohol, etc.)
Documentation review/audit worksheet
there are specific requirements of documentation.
1. Problem focused (PF) chief complaint; brief history of present illness or problems
2. Expanded problem focused (EPF) chief complain; brief HPI problem-pertinent system review
3. Detailed (D) - Chief complaint; extended history of present illness; problem-pertinent system review extended to include a review of a limited number of additional systems; pertinent past, family, or social history direcdtly related to the patient's problems
4. Comprehensive (C) - chief complaint; extended HPI: ROS that is directly related to the problem identified in the history of the present illness, plus a review of all additional body systems; complete PFSH.
Levels of History
Physical Examination (PE or PX)
objective in nature consists of physcian's findings by examination or test results
Physical exam Types
1. Problem focused (PF)
2. Expanded problem focused (EPF)
3. Detailed (D)
4. Comprehensive (C)
Problem focused (PF) physical exam
A limited exam of affected body area or organ
Expanded Problem focused (EPF) physical exam
A limited exam of affected body area or organ system and other symptomatic or related organ systems.
Detailed (D) physical exam
An extended examination of the affected body areas and other symptomatic or related organ systems.
Comprehensive (C ) physical exam
A general multisystem examination or complete examination of a single organ system.
means underlying disease or other conditions present at the time of the visit.
Medical decision making (four types)
1. straighforward (SF)
2. low complexity (LC)
3. moderate complexity (MC
4. high complexity (HC)
new patient (NP)
one who has not recieved any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past 3 years
patient who has received professional services from the physican or another physician of the same specialty who belongs to the same group practice with the past 3 years
includes services rendered by a physician whose opinion or advise is requested by another physican or agency in the evaluation or treatment of a patient's illness or a suspected problem.
transfer of the total or specific care of a patient from physician to another for known problems. Not a consultation, ex. patient with fracture sent to orthopedist
providing of similar services (e.g., hospital visits) to the same patient by more than one physician on the same day. (ex. cardiologist and endocrinologist)
continuity of care
(e.g., a patient who has received treatment for a condition and is then referred by the physician to a second physician for treatment for the same condition),
intensive care provided in a variety of acute life-threatening conditions requiring constant "full attention" by a physician. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition.
it may be given by the physician in a hospital ED or in a physician's office setting. Emergency care is that is provided to acutely ill patients and may or may not involve organ system failure, but does require immediate medical attention.
Emergency medical condition as defined by Medicare
medical condition that manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediately medical attention could reasonably be expected to result in placing the patients health in serious jeopardy, serious impairment to body functions, or serious dysfunction of any body organ or part.
Lay person definition of an emergency
Any medical condition of a recent onset and severity , including but not limited to severe pain, that would lead a produent lay person, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injry is of such a nature that failure to obtain immediate medical care could result in placing the patient's health in serious jeopardy, seirous impairment to bodily functions, or serious dysfunction of bodily organ or part
discussion with a patient, family, or both concerning one or more of the following: diagnostic results, impressions, or recommended diagnostic studies; prognosis; risks and benefits of treatment options; instructions for treatment or follow-up; importance of complication with chose treatment options; risk factor reduction, and patient and family eduction.
AMA policy on abbreviations
should be eliminated from vital sections of health record, such as final diagnosis, operative notes, discharge summaries, and descriptions of special procedures
term including the name of a person (e.lg. Graves' disease)) s hould not be used when a comparable anatomic term can be used in its place
ex. "Buerger's disease compared to thromboangitis obliterans
a condition that runs a short but relative severe course
a condition persisting over a long period of time
diagnostic terminology and abbreviations
problems can occur with documentation because of missing or misused essential words (ex. diastolic dysfunction instead of heart failure due to diastolic dysfunction
within normal limits (WNL), noncontributroy, negative/normal, other than the above, all systems were normal
may not support billing of services, instead, documentation must indicate exatly which limb was examined and abbreviated wording would not pass an audit.
"CANNED" notes mean no assessment was actually performed, this is fraud.
Detailed documentation justifies billed services by providing verification
ex. chest x-ray report reviewed, or read instead of "chest x-ray negative"
a) preoperative vs postoperative, (b) simple/intermediate/complex (c) undermining (d) take down (e) lysis of adhesion (f) surgical position (g) surgical approach (ex. vaginal vs. abdominal
(preop) period before a surgical procedure, begins with the first preparation to a patient fore surgery and ends with anestheia in operating room
(PO) period of time after surgery, beginning with patient emerging from anesthesia and continues through time required for acute effects of anestheia and surgical procedures to decrease
surgical procedures for integumentary system
(example, repair of lacerations) listed as simple, intermediate or complex repairs. Documentation should liste the length (in centimeters) of all incisions and layers of involved tissues sothat correct procedure codes for excision of lesions and type of repair can be determined.
simple laceration (superficial)
one layer closure
requires layered closure of one or more of the deeper layers of the skin and tissues
require more than layered closure and may require reconstructive surgery
If time is factor in coding for reimbursement.
Document length of time spent on procedure, especially if of unusual duration such as prolonged services, counseling, or team conferences. Stated somewhere in the report.
State of art equipment
Surgical procedures one of two categories
therapeutic or cosmetic procedures
cut in a horizontal fashion
to take apart
lysis of adhesions
destruction of scar tissue
key words that may affect coding
- bilateral ( pertaining to both sides)
- blood loss of more than 600 ml (severe bleeding)
- complete or total (entire or whole)
- complicated by (involved with other situations at the same time)
- hemorrhage (escape of blood from vessels; bleeding)
- initial: (first procedure or service)
- multiple (affecting many parts of the body at the same time)
- partial: (only a part, not complete)
- prolonged procedure due to (series of steps extended in time to get desired result)
- simple (single and not compound or complex)
- subsequent (second or more procedures or services)
- surgical (pertaining to surgery)
- uncomplicated or straightforward (not intricately involved)
- unilateral (pertaining to one side)
- unusual findings or circumstances (rare or not usual conclusion)
- very difficult (hard to do, requiring extra effort and skill)
prospectus review, prebilling audit or review done periodically (daily, weekly, monthly)
Prospectus review, stage 1
review to verify that completed encounter forms match patients seen according to appointment book and have been posted on daysheet, then see if all charges are posted
Prospectus review, stage 2
review verifies all procedures or services and diagoses listed on encounter form match data on the insuranc eclaim form.
review done after billing insurance carrier, usually done by biller/coder to determine if sufficient documentation exists
When diagnosis not completed correctly in health record:
an active dx has not been entered i nto the computer system and the computer defaults to the last dx given for established patient. OR dx is not linked to proceudre.
PROBLEMS MUST BE FOUND BEFORE BILLING AND CORRECTED BEFORE CLAIMS ARE PRINTED
red flag in billing looking for billing excesses or potential abuse
unusual billing patterns
same dx code every visit
same procedure code repeatedly
lack of documentation
tests documented but not performed
same level of service consistently billed
pg 114 & 115 discusses HIPAA credited to prevent fraud
discusses physician compliance programs
composed of policies and procedures to accomplish uniformity, consistency and conformity in medical record keeping that fulfills official requirements.
Compliance program elements or Elements of a Successful Compliance program
1. written standards of conduct
2. written policies and procedures
3. compliance officer and/or committee to operate and monitor the program
4. training program for all affected employees.
5. process to give complaints anonymously
6. internal audit performed routinely
7. investigation and remediation plan for problems that develop
8. response plan for improper or illegal activities
software edit checks
audit prevent measure. Software program automatically screens transmitted insurance claims and electornically examins them for errors and/or conflict code entries.
levels of service
insurance carriers expect to see different levels of service listed. If services are downcoded and physician neglected to document correct level of service, an addendum to medical record must be made to justify level of service reported. Amended chartge notes must be labeled "addendum" or "Late entry" dated on day of amendment and signed by physician.
Fax transmissions for insurance claims
unless otherwise prohibited by state law, information that is transmitted by fax is acceptable, and may be filed iwth the patient's health record.
1. fax is derived from facsimile
2. state law may prohibit transmitting claims information by fax
3. sensitive information should have a cover sheet
4. confirm the fax arrived at destination
from legal standpoint, protecting patient's confidentiality in fax process crucial. PATIENT MUST SIGN AUTHORIZATION TO RELEASE INFORMATION VIA FAX.
fax machines should be in secure, private location. a cover sheet always used containing recipient name, sender, date, total of pages, fax telephone numbers, a statement of personal, priviledged and confidential medical information intended for the named recipient only. with request that authorized receiver sign and return attached receipt form at bottom of cover letter. use coded reference number
AHIMA vs fax machine
do not use fax machines routinely
1. hand or mail delivery will not meet needs of immediate patient care
2. required by a third party for ongoing certification of payment for hospitalized patient
do not fax
1. STD, HIV, Alcohol or drug treatment . Psychiatric and psychotherapy records, patient financial data
transmittal verification /
verify fax was received or ensure fax received at destination or run log from fax machine
Medicare fax policy
check with medicare fiscal intermediarey as to acceptability in faxing
under penalty - writ requiring the appearance of a witness at a trial or other proceeding, see details on pp 118-120
subpoena duces tecum
requires witness to appear an dbring or send certain records in his possession
protected health information
electronically store information
concern that they may be altered, overwritten without leaving any evidence, or stored in several computer systems. Metadata or supportive data that is information on the computer system about the medical data,
supportive data that is information on the computer system about the medical data such as
- substantive data is application based and may contain modifications, edits, or comments
- system-based data includes author, date and time when the entry was created, and date of modification
- embedded data is text, numbers, content direcdtly imput but not visible on output (eg., spreadsheet formulas or hyperlinks)
subpoena issued by notary public
retention of records
preservation of health records governed by federal, state and local laws. see pp 120
Federal False Claims Act
proof materials for the establishment of evidence should be kept indefinitely in event of legal inquiry. Calendars, appointment books and telephone logs also should be filed and stored.
Federal Rules of Civil Procedure
makes requests for electronic data a standard part of the discovery process during federal lawsuits including health, accounting phone, instant messaging and electronic mail that might be needed for future litigation
HIPAA NPP acknowledgements
kept for at least 6 years from date of creation
Termination of a case
physican may terminate a contract
- sending a certified letter of withdrawal to patient (if refused by patient, file returned letter in patient's chart)
- sending a certfieid letter of confirmation of discharge when patient states that he or she no longer desires care
- send letter confirming that the patient left the hospital against medical advise or the advise of physician, UNLESS signed statement in patient's hospital records
Prevention of legal Problems
see box 4-1 on pp 124-125
Reasons for proper medical record Documentation (four)
every patient seen by physician must have comprehensive legible documentation about what occurred during the visit for the following reasons; (1) avoidance of denied or delayed paments
2. enforcement of medical record keeping rules by insurance carriers
3. suppoena of health record by state investigators or the court for review
4. defense of a professional liability claim
Electronic health record as tool
foremost tool of clinical care and communication
Medical records evolving into electronic media
HIPAA directs adoption of national electronic standard
CMS introduced documentation guidelines to Medicare carriers
ensures that services paid for have been provided and were medically necessary and that documentation must support the level of service and each procedure rendered
External and internal audits
show where deficiencies occur in health record documentations and substantiantes proper use of diagnostic and procedure codes
HIPAA medical records
must be signed or electronically verified by provider to show the note was reviewed and the test results were acknowledge
Levels of E/M services are based on four types of physical examination: .
problem focused, expanded problem focused, detailed, and comprensive
retention of Records for living patients
Usual policy of physicans to retain medical records
Error corrections for paper chart
Use a permanent ink pen to cross out an incorrect entry on patient's record, mark though it with single line, and write the correct infoeramtion, then date an initial the entry.
Error corrections for electronic medical record
note that a section is in error with date and time and enter the correct information with a notation of when and why the physician changed the entry. Authenticate the correction via electronic signature and date. ALSO, could flag record as amended or obsolete and create an addendum either typed as a separate document or for a chart note inserted belowe in the next space availab.e
A. physician handwrites or dictates notes for patient visit
B. a transcriptionist or correctionist
c. receptionist/medical assistant
D. insurance billing specialist enters codes and/or claim information
In the original or natural place or site.
history of present illness
drug & dosage
return visit information or referral
Physician charting methods
Function of the Medical Chart
Documents health information of patients
Resource for treatment planning
Mechanism of ____communication____ among health care providers
Serves as a __legal document_ _for a patient's healthcare information
Since it is a legal document must careful in what you write in the chart
Types of Medical Charts
Characteristics of Paper Chart
Storage: 3-ring binder
Hard cover protects paper
Sheets of paper can be easily manipulated
Can be used multiple times
Separated into logical sections by __tabbed______ dividers
Each tab is labeled with section heading
Characteristics of Electronic Chart
Patient information is entered into a computer software program that is available throughout the hospital
Information separated into sections like a paper chart
Advantages over paper charts
Eliminates problems with _illegible___ writing
Easy to access data from previous admissions
Software may interface with labs, diagnostics, etc.
Software may offer physician order entry
Using a Medical Chart: Flagging
Each facility has policies for medical chart use
Process used to identify patient order status
Used to communicate what should be done next to ensure completion of patient orders
Color-coordinated to communicate importance level of orders
Binder _positioning__ or placement
Using a Medical Chart:Clipboards or Clip Charts
Extension of the medical chart
Contains _daily_ information that is frequently updated or referenced
Frees up medical chart for use
Information filed in the medical chart at end of day
Used for day to day type of information blood pressure, glucose if diabetic, temperature, so you do not have to carry the entire chart.
Typical Locations to Find a Medical Patient Chart
Rolling Chart Rack
Outside Patient's Room
Where can the chart always be found?
Chart ALWAYS travels with the _patient
Patient goes to operating room - operating room
Patient is on the floor - on the floor
-For long periods of hospitalization
Chart is _thinned_ - infrequently used information is removed
Removed information is still stored on patient floor
Graphic charts (flow sheets)
Operating room procedures
History and _Physical_______
_Medication Administration Report (MAR)
Sections of the Patient Medical Chart
What information does the Admitting Data contain?
-Standardized forms forms generally used
-Located at the front of chart
-Contains biographical data including:
Provides data to billing department
__Date______ and __Time______ of admission
Name of admitting physician
Besides information, what else must be filed under admitting data?
Documents risks and benefits of a specific action that takes place during admission
Release of information
Photographs, videotapes, film of patient
Health Insurance Portability and Accountability Act (HIPAA) forms
Even the smallest amount of risks.
All types of FORMS are going to be in admitting data.
What comes after Admitting data?
__Directives______ for patient treatment
Types of orders
What are physician orders and what types are there?
What follows physician orders?
What are graphic charts also known as and what information do the contain?
Also known as _flowsheets_______
Standardized forms that simplify data collection and retrieval
Quantitative records of _repetitive monitoring activities
Arranged to easily visualize __trends______ and _patterns
Can be standardized to specific nursing units or patients receiving special therapy
Name examples what information can be obtained from graphic charts.
Intake and output
What is the section of the patient's chart after graphic charts?
What are nursing notes exactly?
Used to document _observations_______ and patient care _activities_______
Builds on info from _graphic charts_
Can be separate section or integrated in physician's progress notes
can be separate or will be part of the progress notes.
What information can be found in nursing notes?
Physical functioning (are they moving)
Behavior/mental status (memory)
PRN medications administered
Pain assessments or interventions
Documentation of care
ANY AS NEEDED MEDICATIONS THAT WERE GIVEN!!!!
Nursing care plans
Nursing admission data
What section of the chart follows nursing notes?
What information can be found in Laboratory Data?
Lab test results are usually contained in one section
Most facilities will have a _computer_______ -based lab system
Patient's most recent values will be reported in the computer review this source _first.
Lab tests results in the chart typically appear in summary form and are updated daily
_Abnormal_ lab values highlighted with *
L = low
H = high
Look at _trends__ when assessing lab data
Look at _clinical_ situation of patient
Never make a decision just on one value such as WBC high from one test/day.
What types of test categories are there in Laboratory Data?
Type and screen
Arterial blood tests
What section follows Laboratory Data?
What is contained in diagnostic procedures and consults?
Presented in standardized format
Results may first be available on computer
Invasive hemodynamic monitoring
Operating Room Procedures
What section follows diagnostic procedures and consults?
What does the Operation Room Procedures section contain?
Contain information of a patient's _operation___
Presented in a typed narrative, graphic, or diagrammatic format
History and Physical a.k.a. the admission note
What section is found after Operation Room Procedures?
What info is found in the History and Physical?
Also called the _admission____ note
Information about the patient's past and present medical history and physical examination findings
Medications current taking, symptoms
Includes _initial_____ impressions or diagnosis of the patient's medical complaint
_SOAP_______ format or variation
What info is only found in History and Physicial?
Why they are here? Medications, symptoms, ONLY PLACE YOU WILL FIND SOCIAL HISTORY!!!
S-Subjective-info the patient provides
O-Objective-observable information (test results, BP readings)
A-Assesment-patient's progress and evaluation of the plan's effectiveness and any newfound problems or diagnosis is noted here
P- Plan- decision to proceed or to alter the plan strategy
What section follows History and Physicial?
What information is found in the Progress Notes?
Provide running commentary of the patient's _condition_______
Document patient's _response___ to treatment from admission to discharge
Who provided care to the patient
What was done for the patient
Where, why, how the patient responded
Sometimes nursing notes are combined
WHO PROVIDED THE CARE? WHY DID SOMETHING HAPPEN? This is where the WHY comes into play. Nurses notes sometimes in here.
What information is only found in the Progress Notes?
WHO PROVIDED THE CARE? WHY DID SOMETHING HAPPEN? This is where the WHY comes into play. Nurses notes sometimes in here.
What the characteristics of a properly written Progress Note?
Handwritten, dictated, or typed
Outline or narrative format
Documentation of errors
Single cross out with _error__ written above
Includes person's initials and date
How are the Progress Notes organized?
Filed in forward or reverse _chronological_ order
Pharmacists contribute to progress notes
Admission medication history
Discharge medication counseling
Provision of drug information
Recommendations to modify therapeutic regimens
Reverse order. The newest day on top. Oldest day on the bottom of stack.
? Medication Administration Record (MAR)
What section is located after Progress Notes
What is listed in MAR section?
Medication administration not documented on MAR
_Physician____ administration - progress notes
Medications given during code - code sheet
Perioperative orders - anesthesia or _operating___ records
What section is after the MAR?
What information is found in Miscellaneous?
Contains information that is not included in other sections
Records from outside hospitals
Documentation of patient's valuables
Who should use the chart?
Healthcare providers within the hospital
Administrative personnel of facility
Patients (have to sign form)
You should only use the chart if needed.
List the people who fall under these categories to use the chart.
Medical records personnel
For outpatient provider
For insurance purposes
Outside the hospital, who else would need to use the chart?
Used as _evidence__ in legal action or suit
Why it is important to document ALL interventions correctly
Malpractice suits may be filed for various reasons
Poor judgment of standard of care
Medication or treatment errors
Adverse drug effects
Students receive valuable instruction from "real life" patient charts
Important to remove all patient identifiers and obtain appropriate permission for use
Charts can provide clinical and health statistics research
Important to obtain IRB and HIPAA approvals prior to commencement of research
What does HIPPA stand for and what did it implement?
Health Insurance _Portability_ and _Accountability_ Act
Created a national standard to protect individuals' medical records and other health information
Sets forth requirements for all healthcare professionals concerning protected health information
What information and steps should you use when assesing a patient?
Medical information is only useful when it is properly understood and accurately interpreted
Use most recent data available
Use similar types of information to help assess patient
Know where new data can be found
Assess the whole picture before arriving at a conclusion
irid/o irit/o ir/I ir/o
the lens of the eye
the lacrimal apparatus
opt/I opt/o optic/o
horny, hard, cornea
tympanic membrane, eardrum, middle ear
eye, vision (ie: ophthalmologist)
sclera, white of the eye, hard
pain, painful condition
bad, difficult, painful
surgical removal, cutting out; a suffix meaning ___ (ie: hysterectomy)
deficient, decreased, below
inflammation; suffix meaning ____ (ie: bursitis)
abnormal condition, disease (Ie: endometriosis)
the surgical creation of an artificial opening to the body surface
cutting, a surgical incision
bleeding, abnormal excessive fluid discharge
flow or discharge
black (ie: melanin)
a surgical puncture to remove fluid for diagnostic purposes or to remove excess fluid
the process of producing a picture or record
picture or record
the time and events surrounding birth
the time and events after birth
away from, negative, absent
toward, to, in the direction of
outside, out of, away from
in, into, not, without
large, abnormal size, long (ie: macroscopic)
small (ie: microscopic)
good, normal, well, easy
the study of
bone marrow, spinal cord
renal pelvis (part of the kidney)
belly side of the body (ie: ventral)
back of the body (ie: dorsal)
front, before (ie: anterior)
situated in the back (ie: posterior)
tail, lower part of the body
cartilage (ie: hypochondriac...1of9 regions of abdominopelvic)
in, within, inside
out of, outside, away from
disease, suffering, feeling, emotion
disease, suffering, feeling, emotion
development, growth, formation
development, growth, formation
control, maintenance of a constant level
liver (ie: hepatitis)
cardi/o (2nd one)
blood (ie: hematology)
synovial membrane, synovial fluid
ost/o oste/o oss/I oss/e
skull (ie: cranial)
crooked, bent, still
to bind, to tie together
curve, swayback, bent
loosening, setting free, destruction, breaking down in disease
vertebrae, vertebral column, backbone
singular noun ending
pertaining to formation
sacrum (skeletal system)
illium (skeletal system)
lamina (skeletal system)
muscul/o my/o myos/o
fascia; fibrous band; a muscle system
ten/o tend/o tendin/o
tendon, stretch out, extend, strain
two, double, twice
hernia, tumor, swelling
fibrous tissue, fiber
abnormal condition, plural of -ium
kines/o or kinesi/o
paralysis, stroke (ie: paraplegic)
tone, stretching, tension
breastbone (ie: sternum)
weakness, lack of strength
condyle (skeletal system)
partial or incomplete paralysis
blood vessel (ie: angioplasty, vascular)
acous/o acoust/o audi/o audit/o ot/o
blood or lymph vessel
plaque, fatty substance
a mixture, blending
blood, blood condition
blood vessels (ie: vascular)
fat (ie: mono lipids)
without, less than
-tic -ic -ac -eal -ior -al -ical -ory -an -ial -ous -ar -ary -ine
-ago -iasis -osis -esis -ion -ia -ism
lymphatic vessels and ducts
tonsils and adenoids
adenoids and tonsils
immune, protection, safe
formative materials of cells
bronch/o , bronchi/o
bronchial tube, bronchus
pneum/o, pnemumo/o, pulmon/o
pleura, side of body
chest, pleural cavity
large intestine (ie: colonoscopy)
an/o, proct/o, rect/o
presence of stones
urinary bladder, cyst, sac of fluid
hernia dia- through, between, apart, complete
stretching, dilation, enlargement
breakdown, separation, setting free, destruction, loosening
shaken together, violently agitated
sensation, feeling (ie: anesthesia)
feeling, nervous sensation, sense of perception
the process of producing a picture or record (ie: sonography)
root, nerve root
having an affinity for
one who or one which
condition, state, or theory
possessing, having, full of
process or condition (noun)
(noun) study of
(noun) one who studies
instrument used to cut slices
to make a surgical artificial opening
an instrument used to record data
picture or record
disease, condition, status, process
(changes -osis from a noun to an adjective)
embryonic or immature cell
an instrument used to measure or count something
decrease in or not enough
process of measuring or counting something
an increase in numbers (when used with blood cells)
in on place (staying)
like or resembling
abnormal growth (adjective)
abnormal protrusion or swelling
an instrument used to look at something
development or formation
fluid-filled saclike structure
producing or forming
flow or discharge
indicates a pathologic condition or an infestation
condition of the urine
suturing or stitching
kill or destroy
stretching or dilation
washing or irrigation
condition or development
seizure or attack
the act or condition of stopping or controlling
substance of cells
abnormal or unusual attraction to
dilation or expansion
medical professional or physicians (noun)
medical professional or physicians (adjective)
stopping or controlling
split, cleft, fissure
instrument used to make thin slices
instrument used to make thin slices in the skin
instrument used to make thin slices in bone
process and procedure of using an instrument to make thin slices
process and procedure of using a dermatome(instrument) to make thin slices in the skin
process and procedure of using a osteotome(instrument) to make thin slices in bone
instrument that records visually
instrument that visually records a x-ray
the product of using a recording instrument. the recording or image produced.
the x-ray recoding or image produced
process or procedure of using an instrument to record visually
process of producing images visually using an x-ray
a measuring instrument
a instrument used to measure temperature
a instrument used to measure lung capacity
process or procedure of using a measuring instrument
process or procedure of using a measuring instrument to measure the pelvis
process or procedure of using a measuring instrument to measure temperature
process or procedure of using a measuring instrument to measure lung capacity
instrument used for examining(usually visually or sound)
instrument used for visually examining the eye
instrument used for visually examining the bladder
instrument used for examining the chest by listening
instrument used for listening to fetal heart sounds
process and procedure of using an instrument to examine
process and procedure of using an instrument to examine the eye
process and procedure of using an instrument to examine the bladder
process and procedure of using an instrument to examine by listening to fetal heart sounds
binding together of a vessel
to cut, pertaining to
pertaining to cut into
pertaining to cut out
process or procedure to excise or to surgically remove
process or procedure to surgically remove the tonsil
process or procedure to surgically remove the appendix
incision into the abdomen
incision into the colon
incision into the the trachea
process or pocedure of fixing and suturing
process or procedure of fixing and suturing the fallopian tubes
process or procedure of fixing and suturing the uterus into place
process or procedure of fixing and suturing the lips into place
process or procedure of reconstructive surgery
process or procedure of nose reconstruction surgery
process or procedure of joint reconstruction surgery
process or procedure of vessel reconstruction
process or procedure of surgical repair
process or procedure to surgically repair the kidney
process or procedure to surgically repair the uterus
process or procedure of artifically establishing a mouth-like opening
process or procedure of artifically est. a mouth-like opening in the colon
process or procedure of artifically est. a mouth-like opening in the ileum
process or procedure of artifically est. a mouth-like opening in the trachea
surgical puncture to remove withdraw or aspirate fluid
surgical puncture to aspirate fluid from a joint
surgical puncture to remove amniotic fluid
process or procedure of crushing or destroying
process or procedure of crushing/destroying a nerve
process or procedure of crushing/destroying a bone
process or procedure of crushing/destroying a stone
pain related to
pain related to
pain related to the nerves
pain related to the ear
pain related to the teeth
pain related to the nerves
pain related to the abdomen
rupture or hernia
thirst, related to
related to excessive thirst
process or procedure of fixing and suturing the testes
process or procedure of bone reconstruction surgery
process or procedure to surgically reapir the fallopian tubes
running togather in a pattern
proceeding or before
symptoms united in a pattern
preceeding a pattern/ early warning before outbreak
related to knowledge
before knowledge/ a prediction of a likely outcome
softening of the bone
process or procedure of enlargement
process or procedure of enlargement of the heart
process or procedure of enlargement of the bladder
destroy or separate
destroy or separate the blood
resembles or similar to
resembles or similar to fat
resembles or similar to mucous
resembles or similar to a shield
resembles or similar to a dagger
urine or urination, related to
related to bacteria in the urine
related to blood in the urine
process or procedure of development from usage
no muscular process of development
excessive process of muscular development from usage
no, not, any or without
without breathing/no breathing
difficult or painful breathing
related to paralysis
half or one side
related to one-sided paralysis
related to paralysis from the neck down
related to voice due to laryngeal issues
related to no voice due to larygneal issues
related to cellular growth or development
related to no cellular growth or development
related to excessive cellular growth or development
related to low cellular growth or development
related to speech
related to no speech/without speech
related to eating or swallowing
related to no eating or swallowing
remarkable weakness on one side
condition of something
unusual reduction of white blood cells
any disease process of something
disease process of the glands
disease process of the heart muscle
disease process of the muscle
tumor, new growth(neoplasm)
new growth of blood
from or out from
painful, faulty, diseased, bad, difficult
above or more than normal
below or less than normal
around or near
on, higher in position, over, or above
from or away from
water or fluid
not, lack of (before a consonant)
not, lack of (before a vowel)
difficult, abnormal, poor, painful
with or together
too much or too many
in or toward
beside, beyond, near, abnormal
in front of
through or complete
bad, painful, difficult
well or easy
water or fluid
one hundred, one hundredth
one hundred, one hundredth
one thousand, one thousandth
one thousand, one thousandth
many or more than one
down from or from--resulting in less than
together or joined
together or joined
above or beyond
above or beyond
without or lack of
without or lack of
outside or, beyond, in addition to
beyond, after, occurring later in a series
across or over
in, into, or not
branching or dividing
to free of, to separate, or to undo
before, in front of
split, cleft, fissure
split, cleft, fissure
both or both sides
M edicine (Prescriptions)
P ast Pertinent History
L ast bowel movement/oral intake
E vents leading to the current complaint·
"PAM HUGS FOSS"
P revious presence· of the symptom· (same chief· complaint)
A llergies (drugs , foods , chemicals , dust· , etc . )
M edicines (any drugs the patient· used)
H ospitalization for any illness· in the past·
U rinary changes (especially if diabetic or elderly)
G astrointestinal complaints (diet changes, bowel movements, etc.)
S leep pattern· (waking up/going to sleep· , etc . )
F amily history· (similar chief· complaints/serious illness)
O B/GYN history· (LMP , abortions , etc . )
S exual habits (active/preferences/ STD , etc.)
S ocial life· (job/house/smoking/alcohol , etc . )
patient medical history 3 parts
past, family and social history
Past medical history:
"the patient's past· experiences with illnesses , operations , injuries and treatments";
"a review· of medical events in the patient's family , including diseases which may be· hereditary or place· the patient· at risk";
"an age-appropriate review· of past· and current activities" .
most important procedure for medical assistant. wash regularly, including beginning of the day, before and after lunch, before using gloves, handling specimens or waste, handling clean and sterile supplies; before and after seeing each patient, after blowing your nose and coughing, after breaks, and before leaving for the day.
aseptic hand washing
records life cycle
The life span of a record as expressed in the five phases of creation, distribution, use, maintenance, and final disposition.
parts of hospital medical record
id sheet; history and physical exam records; consent forms; physician's progress records; physician order sheets; lab reports; consultation reports; discharge summary
explanation of benefits
explanation of benefits
document sent by the insurance company to the provider and insured explaining what was covered for each service.
Must be obtained from a conscious, competent adult before treatment. Parent must be legal age and rational. Patient must be informed.
Assumption on behalf of a person unable to give consent that he or she would have done so.
A written agreement to participate in a study made by an adult who has been informed of all the risks that participation may entail.
patient bill of rights
a development by the American Medical Association that guarantees a patient the right to receive courteous, considerate,respectful treatment in a clean/safe environment; appropriate healthcare; information about his/her health treatment plan in a way that he or she understands; a continuity of care; confidentiality privacy;participation in planning care and treatment;refusal of care; use of grievance mechanisms; treatment without discrimination;an itemized bill and explanation of all charges; and review of the medical record and/or copy at reasonable fee.
material data safety sheet
procedures for handling or working with that substance· in a safe manner· , and includes information such as physical data ( melting point·, boiling point·, flash· point·, etc.), toxicity , health effects , first· aid·, reactivity·, storage· , disposal· , protective equipment· , and spill-handling procedures . MSDS formats can vary· from source· to source· within a country· depending on national· requirements .
material data safety sheet
Usually includes an annual deductible and coverage begins after it has been fully paid . Coverage is sometimes available prior to meeting that deductible for services such as doctor· visits (which require· a low· Co-pay) .
Includes a network of physicians , hospitals , and specialists that have· agreed to offer· services at a reduced fee· .
No referral· from a primary care· physician· is required to see· a specialist· .
Allows the flexibility to visit· providers outside the network for a slightly higher fee· and a separate deductible .
Often requires a claim· to be· filed before your benefit· reimbursement can be· made .
Co-pays and monthly premiums are typically higher than that of an HMO plan· (see below) due to the flexibility .
preferred provider organization
usually have· co-pays and monthly premiums that are lower than those of a PPO plan· .
There is a network of physicians , hospitals , and other specialists offering services at a reduced fee· .
The patient· chooses a primary care· physician· who helps coordinate the patient's care· . This physician· must provide· a referral· for the patient· to see· an in-network specialist· .
No coverage for providers outside of the network of physicians , hospitals , and specialists , meaning you're charged the full· fee· if you choose· to visit· them , with the exception· of medical emergencies .
Few or no claims to be· filed , since the insurance· company· pays the provider· directly
health maintenance organization
Health savings account
, A tax-advantaged personal savings account, set up to be used exclusively for medical expenses; must be paired with a high-deductible health insurance policy
health savings account
. icd 9
outdated used to collect information about diseases and injuries and to classify diagnoses and procedures
Bones , axial skeleton· , appendicular skeleton· , and joints
Muscles and tendons
Skin , hair· , nails , and glands in skin·
Eyes , ears , nose· , skin· receptors , and mouth·
Heart , blood· vessels , and blood·
Tonsils , spleen· , thymus , lymph nodes , lymphatic vessels , and lymph fluid
Nose, pharynx, larynx, trachea, bronchi, and lungs
Mouth , esophagus· , stomach , small· and large· intestines , pancreas , liver , and gallbladder
Hormones, pituitary gland, thyroid, adrenal glands, pancreas, and gonads
Brain , spinal cord· , ganglia , nerves , and sensory· organs
Kidneys, ureters, bladder, and urethra
Ovaries, uterine tubes, uterus, and vagina in females; testes, ducts, penis, urethra, and prostate in males
Eyelid or eyelash
Cheek (on the face)
Angle of the eyelids
Keck or cervix (neck of the uterus)
Eyelash or eyelid, or small hair-like processes
Pupil of eye
Derm/a, derm/o, dermat/o
Back or posterior
Gums in mouth
Iris of eye
Abdomen, loin or flank
Back of the head
Neck or necklike
Hair or hairlike
Front of body
Common bile duct
Bladder or cyst
Ilium (pelvic bone)
Cornea of eye, horny tissue
Stone (in gallbladder or kidney)
Bone marrow or spinal cord
Oss/eo, oss/i, ost/e, ost/eo
Roof of mouth
Pleura, rib (side)
Gray matter of nervous system
Pelvis of kidney
Ur/e, ur/ea, ur/eo, urin/o, ur/o
Viscera (internal organs)
Lack of, without, not
Before, in front of, or forward \
Opposing or against
Double, two, twice, both
Co-, con-, com-
Together or with
Down, or from
Twice or two
Beyond, outside of, or outward
Half, half of
Above, excessive, beyond
Below, beneath, deficient
Into, or within
After, or following, behind
In front of, before, preceding
Through or across
-ac, -ic, -al, -ous, -tic
Related to, or pertaining to
Subject to, use
-ent, -er, -ist
federation of state medical boards
Education Commission for foreign medical graduates
National Committee For Quality Assurance
American Osteopathic association
agency for healthcare research and quality
National association medical staff services
Det Norske Veritas
drug enforcement agency
American society healthcare risk management
American health information management association
council for affordable quality healthcare
Accreditation Association for Ambulatory Health Care
American Health Lawyers Association
cause and effect diagram
span of supervision
max number of subordinates a manager can effectively supervise
five traditional functions of management
planning, organizing, staffing, directing, controlling
A time and activity bar chart that is used for planning, managing, and controlling major programs that have a distinct beginning and end.
histogram, ordered by frequency of occurrence, that shows how many results were generated by each identified cause.
a graphical network model that depicts a project's tasks and the relationships between those tasks
A face-to-face communication technique in which a manager walks around a work area and talks informally with employees about issues and concerns
management by wandering around
relating to, involving, or typical of fever
abnormal growth of white blood cells
lines body cavities open to outside
movement of body toward midline
31 pairs of nerves
failure of bone marrow to produce red blood cells
which nerve stimulates diaphragm
intimate touching to 1.5 ft
1.5 to 4 ft
12 to 15 ft
To release info patient must
sign release form
Muscle site in the upper extremity that is used as an injection site is
big part of brain
Gustatory receptors in
Managed care gatekeeper
message, receiver, feedback, sender
If the physician accepts assignment of benefits should be on
insurance claim form
Personal mail goes on
Confidential on mail goes
below return address
future events arranged in chronological order
direction to look for additional codes
comparison of ledger card totals and account receivable bonus
Bank statement reconciled with
New employee must complete
In double entry booking original entry is put
in daily log
fee for service
Medicare part B
regular monthly premium
health care financing administration
CMS developed by
POMR main example
occurs when patient pays in advance
Credit balance on account
Aural temp is in
Placed most recent on top to oldest on bottom
how are test results arranged?
Patient registration record
demographic and billing information; placed in front of chart; may include copy of insurance card and photo identification
Chief complaint; past medical history; family history; present illness; social history; occupational history; physical examination; test history; consultations; past medical records; correspondence; progress notes; medical and prescription record; immunization record; consent forms; release of information form; patient registration record
parts of medical chart
Patient registration record
demographic and billing information; placed in front of chart; may include copy insurance and photo ID
Source oriented medical record
observations and data are categorized according to their source; forms are filed in reverse chronological order (most recent on top); information filed in separate sections
Problem oriented medical record
data are organized according to patient's disease or condition; divided into four parts (database, problem list, plan, progress notes)
part of POMR; includes CC, PI, PE, and lab results; each condition gets own page
numbered and titled list of every patient complaint; part of POMR
diagnostic and treatment decisions for the condition; each plan titled and numbered
structured notes that correspond to each problem number; uses the acronyms
Errors in charting
Current, complete, concise correct, confidential, clean
six cs of charting
process of moving file from active to inactive
transforming written or dictated medical info into a permanent doc
Condition, inspect and release, index and code, sort, store
check for damage, remove pins, staple grouped docs, date your work
Inspect and release
docs can't be filed until the responsible parties have seen the doc and taken action, release mark must be noted
Index and code
determine where documents should be filed, identify the caption, include date and patient name
arrange the docs
Place docs in appropriate place
Personal health record
Electronic health records which are stored on the patient's own computer system.
Temp for patient comfort
answers telephones, schedule apts, registering patient, handling complaints, preparing charts, handling nonpatient visitors
Communication over a distance by cable, telegraph, telephone, or broadcasting
Open office hours (open booking)
clinic is open only for specified time period; patients seen in order of arrival; least efficient method of scheduling; common among urgent care; uses triage
used to screen and classify sick or patients for priority
Flexible office hours
clinic is open additional hours besides normal hours; accommodates various work schedules; usually used in group schedules
Time specified aka stream scheduling
most common; each patient given specific time based on reason for apt; does not accommodate sudden illness or walk ins;
gives short term flexibility within each hour; patients are scheduled in block (6 per hour, etc); system allows for late arrivals; variable waiting time may result
appoints are staggered through the health care provider hour
scheduling 2 patients at once; can be wavelike
similar procedures are scheduled at a specific time of day
requires 2 year course and license
Planning; organizing; coordinating; directing; controlling
Process of Management
the way the leader tells what, when how ,where and who is to perform the task
the way the leader communicates, listens, supports, and facilitates the assisting employees in performing a specific task
Recruiting, interviewing, checking references, selection, offer, negotiation, acceptance
process of recording, classifying, summarizing, reporting, analyzing, and interpreting financial data
property owned or controlled by a business
debt obligation of the business
amount by which assets exceed liabilities; net worth
liabilities+ owner's equity
Single entry system
journal, cash payment journal, accounts receivable ledger
record of charges and receipts
cash payment journal
Accounts receivable ledger
record of the amounts that patients owe the office
Pegboard (write it once) system
most common; all transactions recorded at one time; uses pegboard, day sheet, ledger card, charge slip/receipt
presented at each visit; payment made each time in small amounts
Double entry system
each transaction recorded in a way that keeps a balance of accounting equation
Total practice management system
accounting software package
to remove petty cash
A form prepared by a business (buyer) and sent to another business (seller/supplier) to order items or services.
fee most frequently charged
range of usual fees charged for the particular service by practitioners of similar training
fee assigned to an unusual service; meets the criteria of ucr
increase or decrease to patient account not due to charges incurred or payments received
provider treats another health care professional for free
Assignment of benefits form
patient's signature requests the insurance company to send insurance proceeds directly to the provider
records of debit and credit activity of a patient in the practice
analysis of accounts receivable indicating 30, 60, 90 and 120 days delinquency
Fair Labor Standards Act
sets minimum wage; requires employers to pay 1.5 if work over 40 hours
Title 7 ,civil rights act 1964
prohibits discrimination based on race, color, religion, or gender
Age Discrimination in Employment Act
prohibits unfair practices in employment regarding people older than 40 years of age
Social security and medicare tax; employers are required to collect these taxes from wages, must submit amount withheld, taxes deducted from pay every day, employer must match them dollar to dollar
withheld tax to support unemployment insurance
Federal Tax Id Number
social security number application form
Wages and Tax Statement
transmittal of income and tax statement
Employee's withholding allowance certificate
employee's annual federal unemployment tax return
employee's quarterly federal tax return
Federal Tax Deposit Coupon Book
IRS form to report income other than wages
translates descriptions of diseases, illnesses, injuries, procedures into numeric codes
ICD-9 CM International Classification of Diseases Ninth Edition clinical modification
volume 1 tabular list of 3 to 5 digit diseases volume 2 alphabetical list of diseases, side effects, and e codes; third volume list of procedures
Health care financing administration; used to report Medicare services
Relative Value Scale
assigned unit value given to commonly performed medical procedure
Resource based relative value scale
fee schedule for medicare for services based on level of resources needed
not elsewhere classifiable
not otherwise specified
ICD 10 CM and PCS
current procedural terminology; 5 digit code; 6 subsections
protection against financial loss by unplanned health related events
organization that provides a comprehensive range of services for prepaid fee
Preferred provider organization
agreement between managed care organization and physician to provide services to employee subscribers at a discount
members must receive services within the network only
Medicare Part A
The part of the Medicare program that pays for hospitalization, care in a skilled nursing facility, home health care, and hospice care.
Medicare Part B
-Pays for hospital outpatient physician and other professional services including OT services provided by independent practitioner
Medicare Part C
(Formerly Medicare plus (+) choice plan) Was created to offer a number of healthcare services in addition to those available under Part A part B. The CMS contracts with managed care plans or provider service organizations to provide Medicare benefits. A premium similar to part B may be required for coverage to take effect.
Medicare part D
Diagnosis related groups
medicare fixed fee structure for hospital billing of inaptient services
morphology of neoplasms
The guidelines that determines which of two married parents with medical coverage from different employers has the primary insurance for a child; the parent whose day of birth is earlier in the calendar year is considered primary
1. A cost-sharing requirement under a health insurance policy providing that the insured will assume a percentage of the costs for covered services. 2. For Medicare, after application of the yearly cash deductible, the portion of the reasonable charges (20%) for which the beneficiary is responsible. 3. In the Medicaid Qualified Medicare Beneficiary program, the amount of payment that is above the rate that Medicae pays for medical services. The state assumes responsibility for payment of this amount
Explanation of benefits
A recap sheet that accompanies a Medicare or Medicaid check, showing breakdown and explanation of payment on a claim is called
A provision attached to a bill - to which it may or may not be related - in order to secure its passage or defeat.
A universal claim form developed by CMS and used by providers of services to bill professional fees to health carriers.
start of chain; supplies nutrition to microorganism
Means of exit
how organism escapes
Means of Transmission
way organisms spread
The immediate transfer of an agent from a reservoir to a susceptible host by direct contact or droplet spread
The transmission of an agent carried from a reservoir to a susceptible host by suspended air particles or by animate (vector) or inanimate (vehicle) intermediaries
Chain of infection
Infectious agent, reservoir, portal of exit, means of transmission, portal of entry and susceptible host.
process of cleaning or removing materials from objects; requires scrubbing objects; first step in sterilization process; uses detergents, ultrasound, antiseptic
agents that remove bacteria, fats, oils, and protein substances
machine that uses sound waves through a liquid to cause a vibration
agent that sanitizes skin
process of removing infectious material from objects; chemical (soap, alcohol, acids, alkalis), UV radiation, desiccation, boiling
drying; disinfecting, can't kill spores
kills bacteria, but not spores or viri
complete destruction of microorganisms; chemical or autoclave
250 F; 20lb pressure for 15 mins
Autoclave is normally run
measurements that indicate a patient's general state of health and homeostasis
Absence of breathing
Difficulty breathing when supine.
ABNORMAL CRACKLING SOUND WHICH OCCURS DURING BREATHING
ABNORMAL SOUNDS HEARD WHEN THE AIRWAY IS OBSTRUCTED, A WHEEZE
pattern of breathing characterized by a gradual increase of depth and sometimes rate to a maximum level, followed by a decrease, resulting in apnea
amount of air being inhaled
measure hemoglobin saturation; normal range 95 to 99 percent; SpO2
instrument to measure blood pressure
unpleasant sensory and emotional experience
Character of the pain; onset of the pain; location of the pain; duration of the pain; what exacerbates the pain; relieves the pain
:COLDER pain acronym
deals with the measurement of size, weight, and proportion of human body
standing; arms at sides musculoskeltal and nervous system exam
patient sits upright with legs dangling over edge; drape sheet across lap; examine head, chest, heart, upper part of part
patient lies flat on the back with arms at the sides; used to examine chest area drape sheet from under arms
Lying on back, knees bent
For transvaginal examination, the patient must be in what position?
examination position in which the client is lying on his or her left side with right knee ﬂexed.
PATIENT REST ON KNEES AND CHEST. BUTTOCKS ARE IN THE AIR, ALSO CALLED "GENUPECTORAL". USED FOR RECTAL AND SIGMOID EXAMS
PATIENT IS PRONE WITH HEAD AND LEGS LOWERED AND THE BUTTOCKS ELEVATED
A semi-sitting position; the head of the bed is raised between 45 and 60 degrees
Head of bed raised approximately 30 degrees; inclination less than Fowler's position; foot of bed may also be raised at knee
An examination or operative position wherein the patient is lying face up and on an incline with the head tilted downward and the table angulated beneath the knees
process of touching and feeling
process of tapping or striking body
forceful passive movement of a joint to determine range of motion
process of listening to the body using stethoscope
process of measurement
illuminate internal eye
illuminate external and internal ear
illuminate the mouth, throat, nose for visual examination
used to test patient's hearing
Patient health history; vital signs; physical examine; specimen collection diagnostic test; discussion with provider
sequence of events at apt
A test in which a substance is applied topically to the skin on a small piece of blotting paper or wet cloth
Allergens are applied to a scratch on the skin
Surgery using extreme cold to destroy cells
A display and recording of the electrical activity of skeletal muscle is called an...
used to reduce pain
SURGICAL REPAIR OF A BLOOD VESSEL
Application of an electric shock to the myocardium through the chest wall to restore normal cardiac rhythm
A WAVE ON THE CARDIAC CYCLE THAT INDICATES VENTRICULAR CONTRACTION
diagnoses and treats blood disorders, bone marrow and coagulation
prevent blood from clotting
INCISION INTO THE CHEST
process of examining the rectal and anal area with an endoscope
(pregnancy) extraction by centesis of amniotic fluid from a pregnant woman (after the 15th week of pregnancy) to aid in the diagnosis of fetal abnormalities
SURGICAL REMOVAL OF THE UTERUS
older adult care
all process involved in the intake and use of nutrients
organic compounds primarily from plants; simple sugars, fiber, etc
storage form of fuel; backup of carbs; help with cushioning
organic substances that occur in minute quantities in plant and animal tissues
A guideline, showing proportions, to help people choose what and how much to eat from each food group.
Liquid diet clear liquid
broth, tea, gelatin
Liquid diet full liquid
broth tea gelatin milk custard strained cream soup, all juices Soft Diet foods with fiber are eliminate; no raw fruits or vegetables; postoperative
Mechanical soft diet
regular diet in which foods are ground, chopped or pureed
restricts components that are GI Irritants
Deficiency of this vitamin is most common cause of non accidental blindness in the world
(Cyanocobalamin) Red blood cell formation
A.K.A. Riboflavin. Water soluble. Deficiency results in: blurred vision, cataracts, and corneal ulcerations. Also dermatitis and cracking of skin and development of anemia
A deficiency of _________ has been associated with convulsions and dermatitis in infants
A special protein called the intrinsic factor is necessary for the absorption of this nutrient
Among the following compounds that serve as coenzymes in metabolism, which is considered a vitamin for human beings?
30. Which mineral should be increased during pregnancy
Antihyperlipidemic: inhibits VLDL synthesis and release of fatty acids from adipose tissue. Lowers LDL cholesterol and triglycerides and raises HDL cholesterol. Tox: flushing, pruritus, liver dysfunction, increased risk of myopathy when combined with statins.
CoEnzyme A; plays a large role in the synthesis of vitamins A & D, cholesterol, steroids, FAs & AAs
An important substance needed for proper repair of the skin and tissues; promotes the production of collagen in the skins dermal tissues; aids in and promotes the skins healing process.
A fat soluble vitamin that prevent rickets. Produced in the skin from exposure to sunlight. Found in fatty fish, eggs and meat
The vitamin produced by the normal flora of the colon in amounts sufficient to meet a person's daily need is....
Rowe elimination diet
begin with a few hypoallergenic foods; if no allergy occurs introduce new food group every 10 days
Activities aimed at improving health and preventing disease by enabling people to increase control over and improve their health
temperature pulse respiration
The use of heat, cold, and electrical stimulation to produce an increase or descries in blood flow
patients who require permanent walking assistance
A radiological technique that provides real-time images of an anatomical region.
Study of Drugs
Physician's Desk Reference
Provides info on uses, precautions, indications, and doses for various drugs; section 1 manufacturer index; section 2 product name index; section 3 product category index; section 4 generic and chemical name index; section 5 production identification; section 6 production information
folded sheet of paper within the drug container or box
mix of oil and water
drug dissolved in alcohol
drug dissolved in a mixture of water, alcohol, and sugar
drug mixed with soap, oil, or water
Adult Dose X (Age ÷ (Age+12)) = Child's Dose
a method of determining a pediatric drug dose for a child younger than 1 year of age, based on the child's age and the usual adult dose (assumes that an adult dose would be appropriate for a 12.5-year-old child)
(Weight in lbs./150)x Adult Dose
3 steps in wound healing
a device used to measure radiation exposure to personnel
Bone breaks through the skin
an uncomplicated fracture in which the broken bones to not pierce the skin
a partial fracture of a bone (usually in children)
compound complex fracture
Open penetration break
a thin membrane lining the closed cavities of the body
membranes that line the abdominopelvic cavity and cover the organs inside
Steps to clean instruments
sanitize, disinfect, sterilize
is the process of removing organic matter from an article through cleaning.
free from all microorganisms
free from contamination caused by harmful bacteria, viruses, or other microorganisms
Diagnose, manage, assess
Results of laboratory tests can be used to
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