baseline review

CLIA waived testing

common designation in ambulatory care, low level complexity

can be done in the home environment/easily in the clinic

non-waived CLIA testing

moderate/high complexity tests
labs doing tests must have a CLIA certificate, undergo regular inspections

performed at labs, in a reference

microscope specimen viewings

CLIA allows urine/body excretions to do microscopic screening in ambulatory care to help diagnose/treat

blood pressure screening risk factors

african american race, overweight, family history, medical history of higher BP

breast cancer screening factors

start at age 40 recommended

pap smear screening factors

every 3 years, age 21-29

every 3-5 years age 30-65

HPV screening

age 30-65 every 3-5 years

cholesterol screening factors

family history should do regular screening

dental exams/cleaning

yearly

lung cancer screening factors

age 50-80, history of smoking in the past 15 years/current smoker

bone density screening

osteoporosis patients, postmenopause age patients younger than 65 (who are at risk)

diabetes screening

every 3 years for adults, or sooner if history

abdominal aortic aneurysm screening

recommended 1x screening, male patients age 65-75 who have history of smoking

hepatitis c screening

recommended 1x screening,

screen if patient has risk factors (1945-1965 dob, blood transfusion/organ transplant pre-1992, illegal drug injection use, chronic liver disease, hiv, aids)

HIV screening

recommended 1x screening,

age 15-65

patient centered medical home

focuses on centralized setting between patient/provider

aim to improve patient experience w focused care and more patient participation in their health, and overall good health to reduce healthcare visits

1. comprehensive, holistic care

2. patients and families are centered, focus on patient needs/preferences throughout their life

3. coordinated care; provider directed care between all services, aided by good comms, ehr

4. accessible services through patient portal

5. quality/safety in delivering health care

accountable care organizations

orgs where providers are associated with specific patient populations

ex: affordable care act patients

more emphasis on the community of where the aco is located/public health and outreach

biopsy

surgical removal of tissue for later examination

foreign object removal

usually use splinter forceps

removal of small growth

extracting cysts, warts, moles

endoscopy

viewing hollow organ/body cavity

ex: larynx, bladder, colon, stomach, abdomen, some joints

colposcopy

views vagina/cervix areas

use lithotomy position

cryosurgery

cold liqiud/cryprobe destroys unwanted tissue

incision and drainage

lancing a pressure buildup from pus/fluid

computerized provider order entry system

interfaces/integrates ehr components to help process and coordinate things

• reduces human error potential

• reduces time to delivery

• improves accuracy

• makes info more readily available

• better comms btwn hc system/pts/providers

emr vs ehr

medical record = electronic medical history, used within one org

health record = contains the emr, can use across different orgs (like clinic, hospital, labs, etc.)

required to report what disease?

communicable and infectious like HIV/AIDS, tuberculosis, stis to LOCAL AND STATE

→ local and state will report to fed govt agencies

ma in emergency situation

• refer to office emergency prep plan

• should know CPR, AED, airway obstruction, bandaging, splinting, and wound management protocols

emergency situation procedure ON THE PHONE

1. obtain critical info (name, contact, location)

2. obtain situation info (what/when it started)

3. status of patient (pulse? breathing? conscious?)

4. follow office policy if status is negative (911, remain on phone etc.)

in spinal injury risk…

don’t move patient

if piereced/penetrated patient…

don’t remove object

if lots of bleeding…

apply pressure and elevate body part

anapylactic shock symptoms

• clammy skin

• weakness

• restlessness

• apathy

→ use epi pen

signs of shock

rush of adrenaline → capillary constriction → low BP/circulation

• apathy

• unresponsive

• dilated pupils

• mottled skin

• unalert/unaware

shock procedures

administer emergency care, call 911

lay patient down and elevate legs/feet slightly (if able) and continue to monitor → do cpr if stop breathing

seizure procedure

• lower patient to floor

• move objects out of their way

• turn patient on their side

• allow rest afterwards

poisoning procedure

symptoms of discolored lips, unusual odor, vomitting

try to remove poison when waiting for 911, monitor vitals

open wound procedure

• hand hygiene → gloves, ppe

sublingual

under tongue

buccal

between cheek/gums

blood pressure positioning

no legs crossed, keep arms leveled/resting on a table or chair at heart level

BP sounds

systolic is first sound of korotkoff

phase 2 is swish

phase 3 is sharp tapping

phase 4 is soft tapping into a muffle

final phase is diastolic pressure

brachial pulse

inner upper arm

good for BP measurement and children

cartoid pressure

on the neck/below jawbone

good in emergencies

radial pulse

thumb side of wrist

temperature measurement

most common is oral

(T)/(AU) temp

tympanic/aural (in the ear)

(Ax) temp

axillary temp (in the armpit)

(R) temp

rectal temp

(TA) temp

temporal artery temp (scanning across the forehead)

patient prep instructions

1. knock before entering, announce yourself, ask for permission

2. explain the procedure (simply)

3. have patients pee before undressing if necessary

4. give instructions about disrobing/dressing gowns, assist if needed

5. let patients know where their stuff is gonna be stored

patient education general goals

1. give information about follow ups/appointments/care instructions/referrals

2. give patient expected wait time for things like labs

3. ask about any questions

icd 10 cm

reason for visit (disease, injury, medical conditions, patient status, etc)

assigned for billing purposes

procedural cpt and hcpcs codes

assigned based on what medical services were given

cpt: (medical services, provider procedures)

hcpcs: (supplies, procedures, other services outside cpt)

verifying authorizations and precertifications

1. verify eligibility

2. verify if insurance covers needed service

3. complete insurance requirements to get authorization for a patient’s service

preauthorization use

specific medical procedures, therapies, diagnoses, specialists, surgeries, hospitalizations

preauthorization necessary info

provider info, patient demographic/insurance info, service description, patient diagnosis (w icd-10-cm code/cpt/hcpcs does), justifications

new patient appointment

appt for pt who has not recieved services from provider/group within 3 years

~60 mins

established patient appointment

appt for a pt who has had appt with same provider/group/specialty within 3 years

~15 mins

comprehensive appointment

new or established pt appt for specific complaints at high coding levels/injuries/chronic conditions
~45-60mins

preventative care appt

ex: physical exam, annual wellness exam, chronic care management appts

preventative care and screenings, review full body

~45-60 mins

urgent care appt

appt necessary for medical care within 24 hrs
~20 mins

patient call procedures

1. ask for patient reason for visit to determine type and time of appt

2. gather info about patient appt type

3. ask for day time preference and give a few options

4. ask about in person/online preferences

screening methods

1. ask for patient demographic info

2. ask for reason for visit

3. check nature of current condition

4. determine if necessary to direct call to another department

USE ACTIVE LISTENING

5. verify 3rd party payer/insurance info and eligibility

6. let patient know of any financial responsibilities/requirements