cert notes 2

How does an MA know a patient understands new Dx (diagnosis) instructions?

  The patient can demonstrate the instructions

CBC

(complete blood count)

Capillary puncture

finger stick) for adults: make sure they are NOT dehydrated, 3 or 4th digit (finger) and warm the site if they have poor circulation

1st step when doing any procedure

ID YOUR PATIENT.

Systolic

Systolic (top number- contraction) is heard with the first sound you hear when you release the blood pressure cuff after you inflate it

Diastolic

(bottom number- relaxation phase) is the last sound you hear

(LUB DUB sound)

When obtaining a blood pressure:

Cuff is placed 1 inch ^ antecubital space  (bend of elbow)

Arm must be midpoint level of the heart

DO NOT CROSS LEGS

CPT

CPT code 5 digits- procedure code that must be on the CMS-1500 claim form for submission to insurance.  (it is the code you use for what procedure was performed ex: office visit,

sonogram,CTscan,xray,ekg/ecg etc)

HCPCS (Healthcare Common Procedure Coding System

codes are used to report medical procedures and services to Medicare, Medicaid,

ICD-10  cm code

 letters and numbers) also has to be on a CMS-1500 claim diagnoses and reason for visits in all health care settings

Rinne hearing test:

use tuning fork over the mastoid process(mastoid bone-near ear) and instruct the patient to raise their hand when they NO longer hear the sound

Ear irrigation-

room temperature solution to prevent shock while administering with a steady flow of pressure to prevent the tympanic membrane from rupturing.

When instilling medication in the eye

place a small ribbon (strip) in the conjunctival sac ( pink eye is known as conjunctivitis)

when irrigating the eye

you flush from inner canthus to outer

Sharps container must be emptied when

⅔ full

Medical asepsis

CLEAN technique used daily in clinical settings

Surgical asepsis

removal of ALL microorganisms used in invasive procedures

Clean catch urine-

pt will use perineal moist wipes to clean perineal area, begin to urinate and collect urine midstream in sterile urine container. DO NOT TOUCH TO SKIN

Weber hearing test

place tuning fork on bridge of forehead,nose or teeth.

unipolar-

chest/precordial leads V1-V6

Bipolar limb leads

I,II,III

Emphysema

a type of lung disease that causes breathless  exposure in workplace can cause illness ex: nail technicians and the powder vapors they breathe in can cause

also coal and wood chopping industry

Kyphosis

-visible upper back thoracic curvature (humpback)

Lordosis

lumbar curvature to lower back (swayback)

Scoliosis-

s curvature (lateral curving)

Pulmonary embolism

blood clot in the lung

TB is bacterial

- Mantoux test is most common test, Intradermal at a 15 degree angle

Diuretic

(water pill, eliminates excessive fluid in the body)  example-Lasix

antihistamine

helps with allergic reactions

Antitussives

suppresses the cough

RUQ-

gallbladder, pancreas

LUQ

-stomach and spleen

RLQ-

appendix, reproductive organs

LLQ-

cecum, rectum 

Incident reports are done to note and document

to prevent future occurrences 

the only people who can prescribe or diagnose

are-physicians, physician's assistant, dentists,nurse practitioners,vet.

First aid

 stop bleeding by applying pressure then sterile gauze 

It is out of your scope of practice

 to prescribe or diagnose anything! 

Referrals-

must include name and diagnosis

Regular referrals- take 3-10 days

urgent

24 hours

when a patient is signing a consent form

Validate that the pt is the one SIGNING the document when acting as a witness.

Medical record documentation:

IF IT IS NOT CHARTED IT IS NOT DONE!!!!!!

Crohn's disease-

 is inflammatory bowel disease- pt must be instructed to make dietary changes

Cirrhosis

 this liver disease usually caused by excessive alcohol intake, they may become jaundice which causes yellowing of skin, nail beds and eyes.

Allergy test-

 test- performed on the back or forearm 2-3 inches lower than the bend of the arm (antecubital space) using intradermal method 

Subject filing

 filed under specific tabs that are in alphabetical order

Numeric filing-

used in large healthcare facilities using numbers

Alphabetic filing-

 filing last, first and middle initial

Tinnitus

 ringing in the ears

Telemedicine

lets you see your health care provider without going to their office.

Modified wave

 scheduling  two people at the same time put the 3rd person is schedule 30 minutes later 

Scheduling pt-

 name and phone number (that way if a pt misses you can quickly call and make a new appointment)

Double booking/scheduling

2 pt scheduled at same time to see the same provider

Wave scheduling-

3 pt at same time , seen in order they arrive

encounter form

When a pt checks out from their appt check their encounter form to see if there is a follow up that needs to be made or a referral sent to another provider.

Copayment

The amount of money that a patient with health insurance pays for each health care service  pts must pay before leaving the office.

Allowed amount-

max amount third party (insurance) will pay for services

Deductible-

money pt has to pay out of pocket prior to insurance paying their percentage.

Coinsurance

is a %::::80/20- insurance will pay 80% and pt 20% once the patient has paid their deductible.

ABN form

 Advance Beneficiary Notice form-pt signs taking responsibility when the provider believes Medicare will most likely not pay for the procedure 

EOB

-explanation of benefits - detailed statement from insurance on what is paid,denied, reduced, amounts applied to deductible, coinsurance and allowed amounts (itemized statement) 

Medicare-

65 older 

hospital  care

routine benefits

prescription drug coverage

Antitussive-

relieve cough

Analgesic-

reduce pain

Anticoagulant-

 delays blood clotting

Antiemetics

reduces nausea and vomiting  (medication ex:ondansetron)

Ampules

 are made of glass containing medications for 1 time use

Vials

are typically larger in size and are used to carry multiple doses of drugs, rubber stopper can be sterilized and reused multiple times

Schedule l drugs

highest potential abuse NO medical use- heroin,mescaline,LSD,marijuana

schedule ll drugs

high potential for abuse- handwritten Rx NO REFILLS, morphine,methadone,oxycodone, hydrocodone,fentanyl, methamphetamine. 

schedule lll drugs

 moderate to low potential for abuse-anabolic steroids, testosterone 

schedule IV- drugs

- low potential-diazepam(Valium-anxiety and sleep med),zolpidem (Ambien-sleep medication),alprazolam(Xanax-anxiety) clonazepam (Klonopin-sedative,panic disorder,anxiety

** max 5 refills

schedule V

small limit of narcotics- found in antitussives( treats cough)

When reading labels on medications

check for sound alike-look alike drugs

Do not ever use abbreviations for medications 

Use TALL man letters to emphasize those medications that could cause confusion 

Parenteral route

bypasses GI tract- injectables

Pharmacokinetics

-study of how medications move through the body

This is why we give lower doses to the elderly

Their metabolism does not work the same as a younger adult

know how many rights to medication administration there are

right patient, right medication, right time, right dose, right route, right education/advice, rights to refuse, right assessment, right evaluation/response, and documentation

Axial skeleton-

skull, vertebral column and ribs

Appendicular-

- legs arms and pelvic girdle

Ligament-

attaches bone to bone 

Axial skeleton

 skull, vertebral column and ribs

Antigen-

foreign substance that are within the body

Antibody

proteins the body create to respond to specific antigens

Chain of custody-

required to ensure that specimen tampering did not occur. Kit is provided with these tests and each person who handles or has contact with specimens has to have their signature on it.

An adult with normal hearing can hear tones at

25 decibels,

An children with normal hearing can hear tones at

15 decibels,

Peak flow meter

forced expiratory volume indicates effectiveness of airflow out of the lungs

spirometry

clamp nose, lips secure around mouthpiece- pt instructions: no large meals 2hr before, no smoking at least 1 hour prior, no bronchodilators at least 6 hrs before

somatic tremors

Choppy interference throughout the tracing is often caused by patient movement, even shivering or chewing gum

ac interference

60-cycle interference; an artifact in the EKG tracing caused by electrical interference a wide, fuzzy baseline

Stress testing

-done in hospital setting, pt is attached to ekg- on a treadmill or stationary bike - wear athletic clothes no heavy meal 2 hours before continue meds, no metal on 

 waveforms

Holter monitor

 ekg is placed pt wears for 24 hours continue normal activity avoid showers or getting wet, push button on event monitor and log for dr to see detail comparison on ekg results 

American Heart association- CABG

( coronary artery bypass graft)

wandering baseline

Inconsistency in the baseline location on the EKG tracing likely caused by poor lead contact or skin applications

EMR

Electronic medical record are digital charts to used within the facility

EHR

Electronic Health record- digital charts that include the EMR to be used between other facilities

Living will

 document  stating what procedures a pt would want or not want example: DNR,blood transfusion, organ donation

Durable power of attorney of healthcare

legal document naming a health care agent or proxy to make a medical decision for patient when they are not able to  ( spiritual counsel)