NHA CCMA

Chief complaint

Primary reason for the office visit.

Geriatric Depression Scale (GDS)

A screening tool used for older adult patients to assess depression.

General Anxiety Disorder (GAD-7) Questionnaire

A screening that tests for mood and anxiety disorders.

History of the present illness

Information that expands on the chief complaint.

Mini Mental Status Examination (MMSE)

A tool used to determine the level of dementia in patients.

Pending order

A request for medication or procedure that has not been filled or completed.

PHQ-9 Questionnaire

A section of the full Patient Health Questionnaire (PHQ) that assesses major depressive disorder and other mental health issues.

Rooming

The process of getting a patient ready for a provider.

Examples of pending orders

Include any routine testing, such as mammograms, colonoscopies, Pap smears, and blood work, scheduled consultations that may have been missed, referral appointments, follow-up appointments, and immunizations.

Aseptic handwashing

Used to reduce the number of micro-organisms on the skin by destroying pathogens.

Medical asepsis

Controls the spread of pathogens and is critical for protecting the health of the patient, the provider, and the staff.

Personal protective equipment

Gear worn when there is a chance of coming in contact with blood or body fluids, including gloves, gowns/aprons, shoe covers, lab coats, masks and respirators, protective eyewear, and face shields.

Safety data sheets

Provide information on the hazards and actions necessary when working with specific chemicals.

Sanitization

The cleaning process that reduces the number of micro-organisms to a safe level.

Sterilization

The complete destruction of all micro-organisms through specific means.

What are factors that modify communication?

Factors include age, language barriers, and patient status, which require medical professionals to adjust their communication techniques to ensure effective understanding.

Conditions unsuitable for telehealth evaluation

Acute conditions that require immediate medical intervention or physical assessment, which necessitate an in-person visit due to the urgency of the situation.

What is the first step of seeing a patient

Check the patient's Electronic Health Record (EHR) for the reason for the visit and any pending orders, gaining a general understanding of the patient's concern and the latest information in their chart.

What is a pending order?

A pending order is a request for medication or procedure that has not been filled or completed.

What are examples of pending orders?

Examples of pending orders include any routine testing, such as mammograms, colonoscopies, Pap smears, and blood work, scheduled consultations that may have been missed, referral appointments, follow-up appointments, and immunizations.

What is the third step of meeting a patient?

The third step is to perform hand hygiene to ensure cleanliness and prevent infection.

What is the fourth step of meeting a patient?

The fourth step is to verify the patient's identity to confirm you have the correct individual before proceeding with the visit.

Why is it important to update a patient's allergies during every visit?

The patient's allergy information should be updated on every visit because a patient may have developed or become aware of a new allergy since their last visit, which could affect the treatment plan.

Why is it important to update a patient's medications during every visit?

to ensure that their chart is always accurate and up to date. This allows for effective care measures between providers and ensures patient safety. It is also crucial to inquire if they have been prescribed any new medications since their last visit, and to ask about over-the-counter (OTC) medications, vitamins, and herbal supplements since many of these can interfere with prescribed medications, such as acetaminophen, fish oil, and OTC Nexium negatively interacting with lisinopril.

Why is it important to update a patient's surgical history during every visit?

The surgical history should always be updated to ensure that the patient chart is accurate and up to date. At times, patients may have procedures at other facilities where their EHR systems do not link together, making it essential to add this information to their chart.

Why is it important to update a patient's family history during every visit?

The family history should be updated at every visit to reflect any changes in the health of the immediate family. For example, if a sibling has recently been diagnosed with breast cancer, the information must be added, and the physician must be made aware of this change. With this new information, the physician may want to monitor or order tests for this patient because of the changes in family history.

Why is it important to update a patient's social history during every visit?

Social history is often an area that involves very personal and highly sensitive information. It is important to always remain professional and refrain from expressions or comments that may come across as judgmental or insensitive. Changes in social history could be significant for the patient's overall health and demonstrate areas the physician may need to monitor in the future. The physician will want to know whether anything has changed that may warrant intervention, such as a patient stating that they recently started smoking, which could allow the physician the opportunity to provide health education on the risks of smoking or prompt them to order an annual chest x-ray to check for changes.

What additional screenings may be conducted if the GAD-7 or PHQ-9 applies or the patient is a fall risk?

If the GAD-7 or PHQ-9 applies, or if the patient is identified as a fall risk, it is necessary to conduct the appropriate screenings. The mini screening provides the physician areas of opportunity to monitor other risk areas. For instance, if an older adult states that they have fallen three times in the past two weeks, the physician may order additional tests to check their gait or balance or order labs to ensure that these falls are not a sign of another complication. Other screenings may also be employed during the office visit.

What is health maintenance in preventive care?

Health maintenance is an important first step in preventive care. It involves discussing and scheduling necessary screenings and procedures with the patient to ensure they are completed each year. It is essential to ask the patient which days are best for them before scheduling appointments to avoid inconvenience and potential rescheduling.

What is the recommended timing for calling a patient before their scheduled appointment?

Call the patient 10 to 15 minutes prior to the scheduled appointment time.

What should be considered infectious regarding patient care?

All body fluids from any patient should be considered infectious.

What is the most common mode of pathogen transmission?

Hands are the most common mode of pathogen transmission.

When is handwashing with soap and water recommended over hand sanitizer?

Handwashing is recommended instead of hand sanitizer when hands are visibly soiled, or if there is an allergy to one or more of the sanitizer ingredients, or if there are symptoms related to contact dermatitis and contact urticaria syndrome such as dryness, irritation, burning, itching, redness, and swelling.

What is the purpose of a respirator fit test?

A fit test ensures the respirator fits properly and provides a secure seal, which is necessary for effective protection.

What should be done before using a respirator?

A medical exam should be conducted prior to respirator use to ensure it will not cause any pulmonary or cardiac distress due to severe underlying conditions.

What is the best eye protection option for a health care worker who wears prescription eyeglasses?

A face shield is the best option, though goggles can be used if they fit securely over the glasses and do not inhibit vision.

What should be inspected on the hands before providing patient care?

Inspect hands for cuts and abrasions, keep nails a quarter-inch long or shorter, and avoid artificial nails, as nonintact skin creates a portal of entry in the chain of infection and long or artificial nails can harbor micro-organisms.

What should be done if visible lacerations, cracks, or nonintact skin are present on the hands?

The nonintact skin should be bandaged after washing hands with a waterproof dressing to add an extra layer of protection.

Why should jewelry be removed before handwashing?

Micro-organisms can live in the crevices and grooves of jewelry.

What should be done before starting the handwashing process regarding the sink?

Stand in front of the sink, being careful not to let the uniform touch the sink, as the sink is a contaminated area that can transfer micro-organisms to the uniform.

What water temperature is recommended for handwashing?

Water that is not too hot or too cold should be used, as extreme temperatures can chap and crack the skin, increasing the risk of infection.

What should be done if the paper towel holder does not automatically dispense?

A paper towel should be removed and set on a clean surface next to the sink in preparation for handwashing.

What technique should be used to prevent contamination when washing hands?

Hands and forearms should be kept below the elbows to help ensure that no splashing occurs onto the uniform.

Why is liquid soap preferred over bar soap for handwashing?

Liquid soap should always be used, rather than bar soap, as bar soap is more likely to be contaminated due to its surface area and risk of being dropped.

How long should hands be lathered with soap during handwashing?

Hands should be rubbed together using firm circular motions for 15 to 20 seconds.

What areas of the hands should be washed thoroughly during handwashing?

All surfaces of the hands, including palms, backs of hands, fingers, and between each finger, should be washed thoroughly.

How far up the wrists should hands be washed?

Hands should be washed to at least 2.54 cm (1 inch) above the wrist to ensure all surfaces are cleaned.

What should be used to clean under fingernails during handwashing?

A disposable orangewood or nail stick should be used to clean under fingernails, as soap and water may not reach that area without focused attention.

How should hands be dried after washing?

Both hands should be patted dry from fingertips to wrists using a paper towel, and the wet paper towel should be discarded.

What is the proper method to turn off the water after handwashing?

Using a clean, dry paper towel, turn off the water and then discard the paper towel to avoid contaminating hands.

what are the Aseptic handwashing guidelines

handwashing or alcohol-based sanitizer should be used after using the toilet facilities, before and after handling a specimen, after touching a contaminated object, before and after eating, and after removing gloves.

what are the CDC hand hygiene guidelines

hand hygiene must be done before and after each patient is examined or treated.

Types of personal protective equipment (PPE) used in health care

Include gloves, gowns/aprons, shoe covers, lab coats, masks and respirators, protective eyewear, and face shields.

Most commonly used PPE in health care

Gloves are the most commonly used personal protective equipment in health care.

Usage of PPE in procedures

Not every type of PPE will be needed for every procedure.

Order of donning PPE

Gown, mask, goggles/face shield, and then gloves.

OSHA's Standard Precautions

A set of guidelines established by the Occupational Safety and Health Administration (OSHA) for preventing transmission of bloodborne pathogens.