Study Guide Ch 11,16,37,45  Fill out and maintain accurate and thorough patient records is the most ____for a Medical Assistant important duty Pt medical history and present condition is found where? Medical record also known as charts Patient care management, patient records are used for ? Continuity/Quality of care, communication tool, research, and legal documentation The medical assistant may help _________ about his condition or its management, as requested by ___________. Educate the patient, the physician Pt illness and reason for visit is found in the ___________. History of Present Illness (HPI) Hospital Discharge Summary generally includes? Admission/Discharge dates, HPI, diagnosis, treatment, follow-up care instructions, physician’s signature, complications (if any) The first document found in a pt’s financial record is? Patient Registration Form Initialing imaging reports helps ? To show who is responsible for the entry also to see if practitioner has reviewed them Where should you interview a patient? Private area to have confidentiality You need to distinguish between signs and symptoms. An example of a sign is ________ A fever, rash, or swelling (what other people can tell) You need to distinguish between signs and symptoms. An example of a symptoms is ________ Headache or Nausea (how you feel inside) Signs are External factors that are seen or measured by others Symptoms are Internal factors that are stated by the patient What does each letter of SOAP stands for Subjective, Objective, Assessment, Plan Blue ink is recommended to ensure what? Originality, readability, and fraud prevention Test results should be record ____________ Immediately and accurately Typical time for an CPE is? 30-60 minutes Typical time for f/u appt is? 5-15 minutes The disadvantage of an open-hours scheduling system is? Uneven patient flow (inefficient downtime for office staff) & long wait times What is time-specified scheduling? Where patients arrive at regular, specified intervals, ensuring the practice of a steady stream of patients Wave scheduling is? Several patients seen in the same hour, seen in order they arrived; determined by dividing the hour by the length of the average visit and then giving that number of patients appointments with the doctor at the beginning of each hour Double-booking? 2 or more patients are scheduled at same time slot, assuming both will be seen within the period Advance scheduling is useful in __________ or __________in which a pts are generally booked wks or months in advance. Annual checkups or consultations Advantages of computerized scheduling? Blocks time for emergency or last-minute visits. Lets staff see the schedule from anywhere in the office. Shows which patients cancel or don’t show up often. Helps find and schedule follow-up appointments easily. Makes reports to track how scheduling is going. Uses colors to organize different types of appointments. Lets you search for open days or times quickly

Fill out and maintain accurate and thorough patient records is the most ____for a Medical Assistant

important duty

Pt medical history and present condition is found where?

Medical record also known as charts

Patient care management, patient records are used for ?

Continuity/Quality of care, communication tool, research, and legal documentation

 The medical assistant may help _________ about his condition or its management, as requested by ___________.

Educate the patient, the physician

Pt illness and reason for visit is found in the ___________.

History of Present Illness (HPI)

Hospital Discharge Summary generally includes?

Admission/Discharge dates, HPI, diagnosis, treatment, follow-up care instructions, physician’s signature, complications (if any)

The first document found in a pt’s financial record is?

Patient Registration Form

Initialing imaging reports helps ?

To show who is responsible for the entry also to see if practitioner has reviewed them

Where should you interview a patient?

Private area to have confidentiality 

You need to  distinguish between signs and symptoms. An example of a sign is ________

A fever, rash, or swelling (what other people can tell)

You need to  distinguish between signs and symptoms. An example of a symptoms is ________

Headache or Nausea (how you feel inside)

Signs are

External factors that are seen or measured by others

Symptoms are

Internal factors that are stated by the patient

What does each letter of SOAP stands for

Subjective, Objective, Assessment, Plan

Blue ink is recommended to ensure what? 

Originality, readability, and fraud prevention

Test results should be record ____________

Immediately and accurately

Typical time for an CPE is?

30-60 minutes

Typical time for f/u appt is?

5-15 minutes

The disadvantage of an open-hours scheduling system is?

Uneven patient flow (inefficient downtime for office staff) & long wait times

What is time-specified scheduling?

Where patients arrive at regular, specified intervals, ensuring the practice of a steady stream of patients

Wave scheduling is?

Several patients seen in the same hour, seen in order they arrived; determined by dividing the hour by the length of the average visit and then giving that number of patients appointments with the doctor at the beginning of each hour

Double-booking?

2 or more patients are scheduled at same time slot, assuming both will be seen within the period

Advance scheduling is useful in __________ or __________in which a pts are generally booked wks or months in advance.

Annual checkups or consultations

Advantages of computerized scheduling?

Blocks time for emergency or last-minute visits.

Lets staff see the schedule from anywhere in the office.

Shows which patients cancel or don’t show up often.

Helps find and schedule follow-up appointments easily.

Makes reports to track how scheduling is going.

Uses colors to organize different types of appointments.

Lets you search for open days or times quickly.

Appt reminders include ?

Cards, Reminder mailing, Confirmation calls, Recall Notices, and E-mail 

When scheduling a pt who is fasting for a procedure, what are some things to consider? 

Early morning and confirm fasting instructions such as the need to fat and when fasting should begin since the test might not be accurate

What does fasting mean?

No food or drinks

What pt requires extra consideration when scheduling and should not be scheduled for late morning?

Diabetic and Fasting patients

Why would a diabetic pt who takes insulin eat meals or snacks at regular times?

To prevent low blood sugar/from blood sugar dropping low

Best way to handle routinely late pts?

Schedule them later in the day/end of the day

Define No-Show? Why is documenting no shows important especially when in the office or phone calls?

No shows are patients who miss appointments without notice; documentation protects the office legally and tracks liability

Why are some reasons you may change the route of temp? 

Age of patient, Patient condition, Safety / infection risk, Accuracy needed, Patient comfort or cooperation

Why would it benefit the office to have a POL?

Faster results, better care, and convenient for office staff

Procedure for weighing a toddler?

Weigh parent + child, then subtract parent’s weight

What is Microbiologic Testing? 

Identifies microorganisms that are pre up sent

Hematologic testing? 

Testing of blood to identify problems with count, size, or number of blood cells

Toxicologic test ?

Testing to identify poisons or other chemicals in the body

Cytology Test?

microscopic examination of cells to diagnosis

Immunology Test?

Testing to identify disorders and disease of the immune system

Blood Banking?

Lab department responsible for processing and storing blood and blood products for transfusion and blood disorder treatments

Urinalysis Test?

Testing urine for kidney disease and other disorders and certain metabolic disorders 

Histology Test?

Microscopic evaluation of tissues to make a diagnosis

Serology Test?

Testing the liquid part of the blood for antibodies against specific microorganisms

Chemistry Test?

Testing for certain substances in the blood, urine or other body fluids

What is the purpose of using an autoclave?

To Sterilize instruments with pressurized steam to clean instruments

A centrifuge is

Spins samples to separate components

Optical Microscope uses

 Light that is concentrated through a condenser and then focused through the object being examined

Ocular is

The eyepiece you use to view an image and also contains a magnifying lens called a 10x lens

Glucometer is used for 

To check blood glucose levels

List the Guidelines for Standard Precautions

Wear gloves for all body fluids

Change gloves between patients

Wash hands after removing gloves

Wear mask/eye protection if splashing possible

Avoid needle sticks and sharp injuries

Never use mouth pipettes

Prevent spills and splashes

Clean spills with 10% bleach

Remove PPE before leaving the lab

A pipette is 

Tool to measure small amounts of liquid

What directions are given for a pt when fasting for a blood test?

To refrain them from eating or drinking especially beginning the night before

Accurate measurement of body Temp?

Rectal is most accurate but to get accurate results use the proper thermometer and follow directions

Urine dipstick 

(POL)

•Pap Smear 

(Reference)

•Blood banking 

(Reference)

•Drug testing 

(Reference)

•Wound Cultures 

(Reference)

•Rapid Influenza

 (POL)

•Electrolytes 

(Reference)

•Lipid Panel 

(Reference)

•Strep Throat 

(POL)

•Hemoglobin A1C 

(Reference)

•Hepatitis B Antibodies 

(Reference)

•Hemoglobin concentration 

(POL)

•Lipid Panel

(Reference)

•Wound Cultures

(Reference)

•Fecal occult blood 

(POL)

•Testing for poisons 

(Reference)

•Urine pregnancy test 

(POL)