NHA CCMA part 1

BMI normal range

18.5-25 = normal weight; 25-30 = overweight

No salutation, all-caps subject line between address/body, left justified, no closing, all-caps signature

full block

Systolic <120, Diastolic <80

Normal BP

Systolic 120-129, Diastolic <80

Elevated BP

Systolic 130-139, Diastolic 80-89

Stage 1 hypertension

Systolic >=140, Diastolic >=90

Stage 2 hypertension

Systolic >180 and/or Diastolic >120

Hypertentive crisis

UCR (Usual/Customary/Reasonable)

Usual = this provider's typical charge; Customary = area norm; Reasonable = justified for case

How to communicate with a deaf patient

Through writing

Coinsurance

Percentage patient has to pay

Intercostal space

Spaces between ribs

EKG leads

Electrodes placed on body to record heart's electrical activity

First action disposing needle/syringe

Drop needle-first into sharps container

Dorsal recumbent/supine

Lying flat on back

Prone

Lying on stomach, head to side

Lithotomy

Lying down, feet in stirrups

Left lateral/Sims

Lying on left side, right leg out, left hand behind head

Problem-oriented (charting)

Structured by patient's problems

Source-oriented (charting)

Structured by data provider

CHEDDAR format

Chief complaint, History, Exam, Details, Drugs, Assessment, Return visit

SOAP format

Subjective, Objective, Assessment, Plan

What else goes in sharps container

Scalpels

Sims position used for

Rectal exams

Subcutaneous injection

Fatty layer; slow-moderate absorption

Transdermal

Patch on skin; slow and steady

Intramuscular

Into muscle; moderate-fast

Intravenous

Into vein; immediate

Buccal

Between cheek and gum; moderate-fast

Swallowed pill; slow-moderate

oral

Through lungs; fast

Inhalation

Topical

On skin surface; slow-moderate

Inserted into rectum; moderate-fast

rectal

Parenteral administration

Bypasses digestive system, direct to bloodstream (IM, IV, SC)

cc

Chief complaint

cbc

Complete blood count

cad

Coronary artery disease

cabg

Coronary artery bypass graft

bpm

Beats per minute

bp

Blood pressure

bmi

Body mass index

bm

Bowel movement

bid

Twice a day

asap

As soon as possible

ama

Against medical advice

ac

Before a meal

acls

Advanced cardiac life support

hx

History

npo

Nothing by mouth

prn

As needed

pc

After meals

tid

3 times a day

qid

4 times a day

q4h / q8h / q12h

Every 4 / 8 / 12 hours

qd

Every day

stat

Immediately

po

By mouth

pr

Rectally

pv

Vaginally

otic

In the ear

opth

In the eye

gtt

Drops

sol

Solution

tab

Tablet

tbsp / tsp

Tablespoon / teaspoon

qs

As much as needed

sig

Write on label

subQ

Subcutaneous

supp

Suppository (rectal)

sl

Sublingual (under tongue)

top

Topical

Antitussive

Suppresses cough reflex

Antihistamine

Relieves runny nose/itchy skin

Antiemetic

Reduces nausea

CPT Category I code

5 digits; services/procedures, used for billing

CPT Category II code

4 digits; optional, tracks performance

CPT Category III code

3 digits; temporary, tracks emerging technology

Insulin injection route

Subcutaneous

Insulin injection angle

45° normal weight; 90° obese patients

Hemoptysis

Coughing up blood

Ptysis

Spitting up

Hematemesis

Vomiting blood

Hematuria

Urinating blood

Non-healing wound

Chronic wound

Pyrexia

Fever/elevated temp

Hypothermia

Abnormally low body temp

Tachypnea

Abnormally rapid breathing

Bradycardia

Abnormally slow heart rate

Distribution

Movement of medication within body

Spirometry

Tests lung function (volume/flow of air)

PCMH (Patient-Centered Medical Home)

Encourages shared decision-making, provider-managed holistic care

Sign of obstructed airway

Hands on throat

Sign vs symptom

Sign = objective/observable; symptom = subjective

Hydrocodone

Narcotic, moderate-severe pain

Narcotic, severe pain

Morphine

Narcotic, mild-moderate pain (Schedule III)

Codein

Oxycodone

Narcotic, mild-moderate pain

Lorazepam

Benzodiazepine, anxiety

Amenorrhea

Absence of menstrual period

Menarche

First menstrual period

Dysmenorrhea

Severe menstrual cramping