Chapter 3: Office Administration Terms and Definitions

Learning Objectives

-Manage patient medical records.

-Obtain patient information and consent for services.

-Schedule inpatient and outpatient admissions and procedures.

-Manage appointment scheduling.

-Adhere to HIPAA regulations concerning insurance.

-Respond during patient refusal of treatment.

-Perform office opening and closing procedures.

-Manage physician's professional schedule.

-Maintain human resources documentation.

-Manage inventory of office supplies.

-Perform basic diagnostic and procedural coding.

advance booking

scheduling appointments for patients on a future date

CEU

Continuing Education Unit; programs to assist the professional to maintain his or her license in their profession

cluster scheduling

grouping appointments for patients with similar problems or procedures

CMS

Centers for Medicare and Medicaid Services; federal agency that administers the Medicare program and works in partnership with state governments to administer Medicaid, the Children's Health Insurance Program (CHIP), and health insurance portability standards

coding

use of numbers and letters to describe illnesses, diseases, and procedures

conditioning

the removal of metal items from paperwork to prepare for placing medical records

controlled substance

medications or substances listed by schedule and controlled under the Controlled Substance Act according the potential for addiction or medical use

database

the area of POMR charting that includes information such as the patient's chief complaint

durable supplies

Supplies that are expensive and not often replaced

DEA

Drug Enforcement Administration; federal agency that regulates controlled substances

Federal Register

the official daily publication for rules, proposed rules, and notices of federal agencies and organizations

filing

method by which medical records are kept to ensure ease in updating and finding of records

Global periods

include all services related to a procedure during a period of time depending on payor guidlines

indexing

order in which paperwork is added to a medical record

Informed consent

a form of patient consent in which the patient has been told and understands the procedure that has been prescribed

inpatient

someone who has been admitted to a hospital or other health care facility

Medicare

a federal program of health insurance for persons 65 years of age and older and others with certain disabilities

non-durable supplies

supplies that are inexpensive, and often used and replaced

objective

in the SOAP format, clinical assessment of a patient, such as test results and information that can be observed by others

open office scheduling

a method of allowing patients to access medical care without making an appointment

outpatient

patient who has received a procedure, treatment or test that does not require an overnight stay

pathology

study of disease

POMR

Problem Oriented Medical Records; divides patient's records into four sections; database, problem, treatment, and progress

privacy rule

a national standard to protect a patient's medical record and health information

radiology

medical specialty that uses imaging to diagnose and treat diseases

releasing

the marking of a document to indicate that the record is ready for filing

Security Rule

A national standard that requires health care professionals to take specific technical precautions to ensure that patient information stored or transmitted in an electronic format remains confidential, accessible, and of a high quality

SOAP

charting format that uses subjective, objective, assessment, and planning to organize the information

tabular list

Volume 1 of the ICD-9-CM containing disease information

wave scheduling

patients scheduled for the same time and seen in the order they arrive