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What is within the scope of practice for a CCMA ?

1. Educating patients on how to take their medication
2. Health promotion of the patient.
3. Performing an EKG.
4. Taking patients vitals.
5. Performing urinalysis.
6. Performing a throat culture.
7. Patient education.

What is outside the scope of practice ?

1. Diagnosing patients.
2. Administering narcotics.
3. Interpreting laboratory results.
4. Pathogenic identification.
5. Performing an Arterial Blood Gas (ABG)

What is assault ?

Open threat of bodily harm against another person.

What is battery ?

An action that causes bodily harm.

How do you define fraud ?

Deception with the intent to deprive another person of his or her own rights.

What is invasion of privacy ?

Intruding on a patients private affairs

Malpractice ?

The negligent delivery of professional services.

Negligence ?

The failure to do something that a reasonably prudent individual would do under similar circumstances.

Spousal abuse/ Intimate partner abuse ?

Provides a list of organizations within the local community that can assist in the situation.

What should you do if you suspect child abuse ?

Report suspected child abuse to the provider.

Tort ?

A civil wrong committed against a person or property. (fraud)

Chain of custody ?

In legal context

What is the purpose of the CLIA ?

Clinical laboratory Improvement Amendment sets quality standards and issues certifications for human laboratories.

Health Insurance Portability and Accountability Act (HIPPA)

Then right to inspect

What are the two main purposes of HIPPA ?

1. To provide continuous health insurance coverage for workers who lose or change their job.
   2.To reduce the administrative burdens and cost of healthcare by standardizing the electronic transmission of administrative and financial transactions and protects the patients personal medical information and confidentiality.

A CCMA cannot disclose what information ?

A Patients information unless authorized.

Discussing a patients medical information is breaking what ?

HIPPA guidelines

Even if you are related to the patient you are required to have what to obtain medical information ?

Consent of the patient

The Joint Commission is responsible for what ?

Regulates that identifying patients is crucial to improving patient safety.

Occupational Safety and Health Administration (OSHA)

1. Federal agency that oversees and regulates safety in the workplace.
2. Training provided to employee at no cost.

Quality Control (QC) promotes what ?

Accurate test results

What is the most important step in ensuring patient safety ?

Is proper identification

Always ask for what two forms of identification to ID a patient ?

FULL NAME
DATE OF BIRTH

Never confirm a patients name and date of birth how ?

By speaking their name and date of birth to them.
If they are not paying attention they may say yes when they didn't hear you.

What is implied consent ?

Extending an arm for phlebotomy
Removing clothes for a medical procedure or examination.

What is informed consent ?

Informing the patient of the risk

What is written consent ?

Must have a patients signature to perform procedure.

Patients bill of rights ?

A list of guarantees for those receiving medical care.

What are some of the rights to the patient covered under patients bill of rights ?

1. Patients have the right to a copy of their medical records.
   2.Guarantees fair treatment.
2. Autonomy over medical decisions and many more rights.

POMR Should always be filled in what order ?
(Problem Oriented Medical Record)

Should always be filled out in chronological order.

Patients have a right to view their medical records at any time.
The information in the medical record belongs to who ?

The medical record belongs to the patient

What is a CMS-1500 form used for ?

Basic standard claim form used by healthcare professionals to request reimbursement for services provided to patients.

Encounter form or Superbill is used for what ?

An itemized form of services submitted to insurance carriers for reimbursement of rendered services. A CCMA would also use this form to check out patients.

Release of information form allows what ?

Allows a patient access to his own medical records and allows the patient control over to whom the medical records are released.

Preferred provider organization (PPO)

Managed care organization of providers

Medicaid provides healthcare coverage for whom ?

Provides health insurance for the medically needy.

Medicare is for ?

Federal insurance plan that generally covers those over the age of 65 and is considered an entitlement because most have paid into the system through there employer.

Tricare is ?

Healthcare for military personal and their dependents to receive care form a civilian provider at the expense of the federal government.

What is the purpose of Workers Compensation ?

Wage replacement and medical benefits for those injured on the job.

Advance Beneficiary Notice (ABN)

Waiver of liability

What is coinsurance ?

An amount a policy holder is responsible for according to their insurance policy.
The policy holder must meet a specific amount before the insurance company will pay their portion.

What is a copay ?

A specific amount of money based on the patients insurance policy that must be paid at time of service.

deductible ?

Specific amount of money a patient must pay out-of-pocket before the insurance carrier begins paying for service in a calendar year.

Explanation of benefits (EOB) ?

A statement detailing what services were paid

Preauthorization ?

A decision by your health insurer or plan that that a health care service

Precertification ?

The process of obtaining eligibility

Referral ?

The process of directing or redirecting to a medical specialist or agency for definitive treatment. (Some insurance companies require this)

Verification of eligibility ?

Before care is provided

CPT ?

Current Procedural Terminology

ICD ?

International classification of disease
Each diagnostic and procedural code allows for submission of services for reimbursement from insurance companies and to provide statistical data for research.

There are how many characters used in ICD ?

Three to Seven

First character is used for what ?

Main term when searching in alphabetical order

Second and third characters ?

Numeric codes

Fourth

Fifth

What is a modifier ?

Indicates one procedure was used multiple times on a patient.

What is Advance Booking ?

Making an appoint for a patient in advance.

What is Clustering ?

Seeing patients on the same day at the same time.

Double Booking ?

Two patients are given the same appointment time.

What should you do if the provider is LATE ?

Offer to reschedule a patients appointment the provider is late.

New Patient ?

A patient who has not been seen by the provider before or who has not been seen in three or more years is considered a new patient for billing purposes.

How should test be scheduled ?

Schedule the least invasive test first if a patient is having multiple test.

Wave scheduling ?

Three or Four patients are scheduled every half hour and are seen in the order in which they arrive at the office.

Aerophagia ?

Swallowing air

alopecia ?

Sudden increased hair loss

Anthropometric ?

Used to asses the size

Chief Complaint (CC) ?

The primary symptom that a patient states as a reason for seeking medical care.

Cirrhosis ?

Chronic liver disease.

Cholecystectomy ?

Removal of the gallbladder.

Dysuria ?

Painful difficult urination

Dextrocardia ?

The heart points to the right side instead of the left.

Electronic Health Record ? (EHR)

Electronic record of patients' health related information and can be created

Electronic Medical Record ? (EMR)

Electronic record of patients' health related information and can be created

Hemostasis ?

Promotes coagulation and stops bleeding.

Hypoglycemia ?

Low blood sugar that can be helped by giving the pt orange juice.

Ischemia ?

Restriction of oxygen rich blood to a portion of the body.

Parathyroid Hormone ?

Hormone secreted by the parathyroid gland that is important in bone growth.

Patient Centered Care ?

Requires the inclusion of both family and patient regarding the patients care.

Pericarditis ?

Inflammation of the pericardium ( Surrounding limning of the heart.)

Personal Protective Equipment ? (PPE)

Equipment that protects the wearer from bodily injury or infection.

OSHA mandates that all PPE be free of what ?

Charge

Petechiae

Broken capillaries due to bleeding under the skin.

What is one reason why petechiae occurs ?

The tourniquet is to tight.

Pyelonephritis?

Inflammation of the kidney which can cause pain in the lower and mid back.

Retinopathy ?

Disease of the retina that results in impairment of vision and can be a complication of diabetes mellitus.

Vertigo ?

Episodes of dizziness and a sensation of spinning with certain head movements.

What are the causes of vertigo ?

Caused by inner ear disorder
Can be caused by performing an ear irrigation on a patient.

SOAP notes

A format for communicating important patient information in a chart in an organized manner.

Subjective
Objective
Assessment
Plan

Information the patient conveys (everything pt states is subjective.)
Measurable information about the patient (vitals

Spirometry ?

Common office test to see how well your lungs work by measuring how much air you inhale

Syncope ?

Fainting

Transition of Care ?

Refers to the cordination and community of healthcare during a movement of a patient from one healthcare setting to another or to home.

ABG's

Arterial Blood Gas

CC

Chief Complaint

CBC

Complete Blood Count

-ectomy

Surgical removal

-itis

Inflammation

Nephr/o

Kidneys

-ology

Study of

Ophth

eye

Oto

ear