CCMA UNIT 1 TEST VOCAB!

Are MAs licensed or certified?

MUST be licenced (certification is GENERALLY optional)

What is the difference between licensure and certification?

licensure is the legal right and responsibility to engage in an activity/occupation

certification is the acknowledgement that the person has completed the requirements to be competent in an occupation

Licensure for physicians moving to another state can be accomplished by what means?

reciprocity or endorsement

What are some examples of Administrative duties of the MA? Clinical duties?

Administrative - Using computer applications, Answering telephones, Greeting patients

Clinical - Taking medical histories, Explaining treatment procedures to patients, Preparing patients for examination

What is Scope of Practice - how is it defined? What are some examples of what MAs are allowed to do? What are they NOT allowed to do?

procedures, actions and processes that a healthcare professional is permitted to undertake in keeping with the terms of his/her professional license or certification

Allowed - Measuring and recording vital signs, Educating and providing instructions to the patients, Removing sutures from minor cuts

Not Allowed - Diagnose patients, Give advice to patients prescribe medications

The two classifications of the MAs duties are…?

clinical and administrative

What is “rooming” a patient? What information must be gathered during this intake process?

the process of gathering initial information such as reason for the visit aka the CC (chief complaint), patient allergies, current medications, changes in health, and recent stays in hospitals or other healthcare facilities.

What is “Standard of Care”?

legal term that refers to the care that would ordinarily be provided by an average, prudent healthcare provider in a given situation.

What is a Patient Navigator?

directs patients through the health care system

Who is considered a provider?

Doctor, Nurse Practitioner, Physician Assistant

What is the difference between Medical Doctors (MD) and Doctors of Osteopathy (DO)? THINK: DO = Holistic

What professions are/are not Allied Health? Are MAs considered Allied Health?

NOT - Chiropractors, Nursing, Nurse Practitioners, Physician Assistants.

***MA’s ARE considered Allied Health

ARE - occupational and physical therapy, dietitians

Be able to identify medical specialists

What is a PCMH? Who is in charge?

Patient Centered Medical Home: is a care delivery model in which A PCP (Primary Care Provider)*coordinates treatment to ensure patients receive required care when they need it.

What does “meaningful use” require? THINK: meaningful use = electronic records

What is CPOE? Are there any restrictions on who enters different types of orders? (This information is in the STATION 1 document and was also a QOD)

physician order entry system

MA’s may enter certain types of orders into the CPOE. ONLY the provider can enter the hospital orders into the CPOE.

Who is legally responsible for the outcomes of the MA’s performance?

provider

What is a “Patient Portal” and what are some of its features and benefits?

allows patients to log into a patient-facing aspect of the EHR to view their personal health information

messaging the healthcare team for questions/concerns scheduling appointments

increased transparency about care and decreased wait times for patients to receive results

The Medical Assistant must be familiar with the population of patients they serve AND must be aware of community services that are available to patients. The MA should…? (in part 1B of notes)

Is an Encounter Form filed in the medical record?

NO, it is NEVER filed in the medical record!

Encounter form

Also known as a “superbill”

The Encounter form is a document used by healthcare providers to record a patient's visit. It contains information that's necessary for billing and reimbursement, including: diagnosis codes, procedure codes, services provided (what was done during the visit followed by the corresponding codes), and supporting information.

Contains information about provider referrals or follow-up appointment requests for the patient.

It MUST always contain the reason for the visit IS NEVER FILED IN THE PATIENT’S CHART

What does an AVS (after visit summary) include? The MA should always review the AVS with the patient at time of check-out.

repeating the physician’s instructions

What types of services are/are not appropriate for Telehealth visits?

ARE - Follow-up on medication adjustments, Chronic condition review and discussion, Patient education

NOT - Diagnostic testing, such as imaging or lab work, New pain symptoms ​​​​​​, Physical examination

Patient “demographic and registration” form. What does the “assign and release” authorize? (you have a copy of this form in your worksheet packet)

• direct financial payment from your insurance company to the healthcare provider

• allows the provider to share your medical records with your insurer to process those claims.

What is a Notice of Privacy Practices form and what is its purpose?

Explains patient rights under Health Insurance Portability and Accountability Act (HIPAA)

Is required to be included in the patient’s record.

Patient sign-in sheets: what should NOT be on it? How can you avoid incidental disclosure of information?

reason for visit , avoid by removing patients info after they have signed in or use electronic stuff

What are hard skills? Soft skills? Give examples.

hard skills - actual work

soft skills - communication

What should occur at every visit?

(A cc [chief complaint] and medication review!)

What did the ADA (Americans with Disabilities act) of 1990 do?

the office must be disability friendly

What is a Tickler File?

file reminder system (organization)

What forms are REQUIRED for new patients?

Notice of Privacy Practices - facility’s privacy policy, explains how their information will be used and disclosed, how they can get access to their medical record.

Release of Information form - lists the people that their health information can be shared

Know what demographic information is

name, telephone #, married status, employer info, address, gender, DOB, date, social security #

What is a Notice of Privacy Practices form and what is its purpose?

Explains patient rights under Health Insurance Portability and Accountability Act (HIPAA)

Is required to be included in the patient’s record.

What is the purpose of the ROI (release of information HIPAA) form?

Signing this form gives the medical office permission to share the patient’s information with other providers involved in the care of the patient.

What is an “established” patient? If they state “no changes” in their information, what should the assistant do?

established - returning patients and they will already have a patient chart in the office.

still make sure and verify info

Should patients be given an explanation of delays? If so, after how long?

always, ASAP

How can an assistant avoid an incidental disclosure when using a patient sign-in sheet? Check your notes!

scratching info out

What is PHI?

Protected Health Information

What must be validated each time the patient checks in?

ID and Insurance information must be validated at each visit