Billing and Coding

Electronic Medical Records (EMR)

computerized records of patient information, including patient care, treatment, outcomes, and details about patient conditions (can not be shared among health organizations)

Electronic Health Records (EHR)

An electronic record of health related information about a patient, can be easily shared among health organizations.

Paper health records

• can be misfiled

• contain information that is difficult to share

• contain hand written notes, requires interpretation

• contain information that can be viewed by only one person at a time

• require more storage space

• need maintenance, time consuming

• results in more errors due to illegible handwriting

Problem oriented Medical Records (POMR)

documents that are organized according to patients health problems, developed in four stages (database, problem list, plan, progress notes)

Source- oriented medical records

documents organized into sections, depending on department, facility, or other source that generated info (EX: radiology, laboratory, hospital, consultant assessment, and treatment)

Subjective contents of health records

• patient social history

• patients family history

• personal and medical history

• personal demographics

• patients chief complaint

Objective contents of health records

• vital signs and measurements (temperature, pulse, blood pressure, pulse oximetry)

• Laboratory and radiology reports

• diagnosis

• treatment prescribed and progress note

• condition at the time of termination or treatment

S.O.A.P Format

(S) - Subjective data

(O) - Objective data

(A) - Assessment

(P) - Plan of action

• Document progress notes in this format

Established patient

a patient who has received services from the same or a different physician of the same specialty within the past three years

New Patient

MA must obtain patients demographics, name, DOB, phone number, and insurance information

Angry callers

• remain calm

• avoid getting defensive

• lower tone of voice

• listen and express interest

Aggressive caller

• calm, poised attitude

• reassure caller

• express interest

• avoid getting deffensive

Unauthorized inquiry callers

explain to caller requested info cannot be provided without authorization based of privacy laws and refer caller to office manager

Sales caller

Keep call quick and to the point, and give sales person an appointment to discuss product

Technology in the Medical Office

• tablets

• voice recognition software

• wireless mobile workstation

• wearable computing device

• Bluetooth headset

• sign in kiosks

• cart reader machines and bar code scanner

• patient tracking systems

Ergonomics

study of improving workstations to reduce employee injury, poor posture, and strain causing physical injury

• document holder

• wrist rest

• arm rest

• lumbar support

• foot rest

Input devices

Help provide data to computer

• keyboard

• mouse

• touchpad

• scanner

• webcam/ microphone

Output devices

• monitor or digital screen

• speaker

• printer

Parts of a professional letter

• senders address

• date

• inside address

• reference line

• salutation/ greeting (“Dear Mr. Smith:”)

• subject like

• body of letter

• closing signature block and end notation

Full Block Letter Format

Most common type of business letter where all elements are left justified, (formal) “closed” punctuation, colon after salutation, (informal)“open” punctuation, comma after salutation

Modified Block Letter Format

Senders address is left justified, when no letterhead and inside address, along with all other elements

date, closing, and signature block are right justified or at center point

Semi- Block Letter Format

senders address left justified when no letterhead and inside address, along with all other elements

date, closing, and signature block right justified or at center point

each paragraph is indented 5 spaces

Different signs in the medical office

• immediate danger signs

• caution signs

• exit signs

• biohazard warning signs

  • radiation symbol signs

R.A.C.E

Rescue, activate, confine, extinguish/ evacuate

P.A.S.S

Pull, aim, squeeze, sweep