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Module 1

Human Relations & Comm. 1 -- Chapters 1-9 (Final Review )

Who is customer service demonstrated by within the medical office? All Employees...Including Doctor, NP, PA, Nurses, MA, Lab Tech, Receptionist, Coder ,Biller
What are the 4 Main General Skills 1. Instruction 2. Communication 3. Medical and Legal Concept 4.Operational Functions
What duties fall under operational functions? Chart Prep, Stocking Exam Rooms, Patient Flow
What type of educational instruction may the MA be responsible for conveying to the patient? Disease prevention, medication management, after care
Why is it important to understand medical law and medical ethics? To understand what may or may not be done within the office. Being aware of "Scope of Practice"
What are some examples of Administrative Skills? Filing, Creating Charts, Admission procedures, Billing, Coding
What are some examples of Clinical Skills? Performing Phlebotomy, EKG, Obtaining Vital Signs, Assisting MD, Collection and handling of Lab Specimens
What does HIPAA stand for? Health Insurance Portability and Accountability Act
What is the purpose of HIPAA Provides Confidentiality to Patient Medical Information and assists in the Prevention of fraud and abuse of insurance
What is Ambulatory Care Medical Care in a clinical setting rather than a hospital or home
Why is proper attire an important role of an MA? Projects Professionalism and Cleanliness is important
What is Active Listening? Responding to your patient, eye contact, repeating what your patient says back to them, nodding
What are the five stages of dying? D- Denial A- Anger B- Bargaining D- Depression A- Acceptance
What is privileged information? Everything a medical assistant sees, hears, or reads in the office
Licensure Credentials mandated by state- cannot practice without
Certification Individuals meet either minimum competency requirements or a level of excellence in the area defined
Registration Issued by a state or national board or association that verifies that a person meets professional standards
Accreditation Can mean either meeting a state standard or Being evaluated and recognized by a national organization
Hospice Care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure
Palliative Care Care can be received by patients at any time, at any stage of illness whether it be terminal or not- usually clinical setting
Documentation Extremely vital to prevent medico-legal professional liability "if it is not documented, it did not happen" Medical Chart is a legal Document
Interpersonal skills are also known as: Soft Skills
What are some examples of Soft Skills? Business Etiquette, Honesty, Versatility, Respect, Active Listening, Commitment
Ambulatory Care Medical care in the office rather than receiving medical care at home or in a hospital
Why is medical assisting considered to be versatile? Medical Assistants perform clinical, administrative and general skills
Integrity Unwavering Adherence to ones beliefs and moral standards
American Association of Medical Assistants (AAMA) National association of medical assistants, medical assisting students, and medical assisting educators with both state and local chapters; recognized by the American Medical Association
Continuing education units (CEU) Credit for course hours that an individual receives for attending or taking part in an educational program
Assertive One who appears confident and is self-assured
Burnout condition that results in too much or too little stress
Aggressive One whose behavior is belligerent, confrontational, pushy, forward, or overbearing
Professionalism conduct aspirations and qualities, characteristics of a professional
Who is considered the "father of medicine" Hippocrates
MCO Managed Care Organization
HMO Health Maintenance Organization
PPO Preferred Provider Organization
EPO Exclusive Provider Organization
Gatekeeper Primary Care Physician- HMO, keeps cost of healthcare down
POS Point of Service Plan
IPA Independent Practice Association
Solo Practice MD owned - Only practioner
Sole Proprietorship MD owned hires other practioners.
Group Practice Three or more physicians share profit and loss Can consist of Partners and employees.
Professional Corporation Managed by Shareholders with Board of Directors Set up so that the Physician has minimal personal loss Hospitals, Urgent Care,Dr Offices owned by hospital
Associate Practice Physicians agree to share expenses such as employee payroll, facility, general expenses, but profit and loss is their own.
Concierge Medical Care AKA "retainer medicine" patient pays an annual fee or retainer
Health Maintenance Organization (HMO) Healthcare services are made available to plan members for a predetermined fee or capitation rate- use a limited group of providers. PCP(Primary Care Physician – serves as gatekeeper. No copay or very Low
Preferred Provider Organization No gatekeeper Can go out of network for an additional fee Copay
Exclusive Provider Organization Combination of HMO and PPO concepts Providers limited to defined group Paid on modified fee- for- service
Holistic Medicine Medical doctors of holistic medicine are usually DO Focus on physical, mental, and social well-being of the “whole” person
DO Doctor of Osteopathy
Point of Service Contracts with independent providers at a discounted rate. Members have a choice at the time service is rendered of receiving services from an HMO, PPO, or fee-for-service plan.
Fee for Service Arrangement in which either the physician’s office or the patient files a claim to the insurance company, and the full amount allowed by the insurance company is collected.
Active listening Giving the speaker your undivided attention, resisting urges to respond verbally, mentally focusing and concentrating on the message being relayed
Defense mechanism Are largely unconscious acts we use to help us deal with the unpleasant and emotional circumstances
Subjective information any information that the patient provides to the physician describing symptoms that exist in the mind but cannot be seen, heard, felt, or measured
Communication the transfer of information from one party to another
Demeanor How a person appears, their expressions and body language
Ethnic A group of society defined by origin or race
Feedback Oral or nonverbal response such as repeating, restatement, paraphrasing, examples, questions, or summaries
Non-verbal communication Communication without words, expressed through body posture, hand movements, manner of walking, and facial expressions; also called body language
Bias To prejudge or have a one-sided opinion that influences your judgment negatively
Communication cycle Basic elements needed to communicate
Enunciate to pronounce things clearly
Verbal communication The use of language or spoken words to transmit messages
Reflective listening To think about, dwell on, mull over, and study or weigh what has been said
Discrimination To unfairly treat an individual or group based on age, culture, gender, race, religion, lifestyle, or sexual orientation
Colloquialisms Slang or informal language
Prejudice Judgment formed prior to gathering all facts
Noncompliance In a medical setting, refusing to obey the doctor's treatment plan
Displaced anger anger that is completely unrelated to the event that is presently occurring; it may be built up or held in from another event and released at an inappropriate time
Stereotyping Generalized or oversimplified conception concerning an individual, group, or form of behavior
Open-ended questions Questions that allow a person to formulate a response and elaborate
Objective information In a medical context, facts that are apparent to the observer; descriptive of findings that can be seen, heard, felt, or measured
Body language Body movements, sending a message without words; referred to as nonverbal communication
Maslow's Hierarchy of Needs Five central human needs arranged from the most basic (bottom of pyramid) to the most complex (Top of Pyramid
Physical Needs Fresh air Clean water Nutritious food Shelter from elements Proper clothing Basic medical care Sexual intimacy
Security Needs/Safety Freedom from physical harm Stable environment Can depend on others Protection from abuse Freedom from fear, anxiety Order, law and limits
Social Needs/Belong/Love Essential need for others Fulfilling relationships with others Romance Friendships
Esteem Needs Feel valuable and worthwhile Feeling of importance Feeling of being successful and respect Competence
Self Actualization Self personal growth Personal Fulfillment = Success
Voice Mail type of answering system used to store and forward messages for someone who is unavailable
Toll Call telephone call for which charges apply
Speakerphone Telephone with a microphone designed for hands-free communication
Telecommunication transmission of voice and/or data using telephone lines or wireless means
Conference Call call in which three or more people at various locations participate
Telephone Reference Aid a sheet of alphabetized names and telephone numbers near a telephone for reference.
Triage process of determining priority order of patients by level of urgency "To Sort"
Telephone Log written, dated record of all telephone calls
Answering service Business that specializes in taking and relaying telephone messages when offices are closed
Screening Process of asking good questions to evaluate and determine the action to be taken on a telephone call or to determine the person who should receive the telephone call
Call backs Term indicating that a return telephone call is necessary
Emergency care Medical care given for a serious medical condition resulting from injury or illness that if not given immediately puts a person's life in danger
Protocol Set of instructions used for reference that prescribes strict adherence to correct etiquette and preference
The most important public relations responsibility of medical assistant is to place, receive, and screen telephone calls for the office.
How long does it take a person to pick up on your attitude from listening to the tone of a voice? On average 10 seconds
When answering a phone call... try to answer within 3 rings and state the name of the practice as well as your own name
The length of time you should check back with a patient on hold every 30 seconds
Speed Dialing- electronically stores frequently dialed numbers
Call Forwarding allows all incoming calls to be automatically directed to another internal station
Caller ID- reveals the name and telephone number on a display panel before the call is answered
Common types of calls in the medical office Appointments/Referrals Emergencies/Hospitals Prescription refills Test results
Appointment card Small card preprinted with the physician's name, address, and telephone number showing the day, date, and time of an appointment; given to the patient to serve as a reminder
Appointment abbreviations Shortened words or coded numbers indicating types of appointments, types of patients, types of insurance, and reasons for appointments
Modified wave System used to schedule appointments in which patients are allocated appointment times in the first half of each hour, with the second half of each hour left open for work-ins and emergencies
Appointment block Segment of time set aside in the appointment schedule for a specific patient type or procedure
Smartphone Mobile phone with advanced computing ability and connectivity
Clustering Act of scheduling patients with similar ailments in group sequence
Template A preset format or pattern, used as a guide which designates various time frames for specific appointment types
Referral Procedure followed when a primary care physician recommends and sends the patient to another physician for further medical treatment
True wave System of appointment scheduling that allows for variables and flexibility and assumes the time allowed for appointments will average out each hour
Appointment schedule List designating chronological fixed times for patients to meet with the physician and/or receive medical services
New patient (NP) Individual who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past 3 years
Personal digital assistant (PDA)- Small, handheld, computerized portable device, easily accessed, that can capture, store, and manipulate a variety of data
Stream System of advance appointment scheduling in which patients are allocated specific periods of time for office visits and procedures; also called fixed interval
Software Computer instructions permanently stored in or temporarily programmed into hardware
Appointment book Set of sheets used to schedule and record time set aside for patients to see health care practitioners for procedures and services
Established patient (est. pt.) Individual who has received professional health care services from the physician or another physician of the same specialty who belongs to the same group practice within the past 3 years
Modified wave System used to schedule appointments in which patients are allocated appointment times in the first half of each hour, with the second half of each hour left open for walk-ins and emergencies
Open access Appointment scheduling system that allows patients to call and come in the same day; also referred to as same-day scheduling, same-day access, and advanced access
No-show (N/S) Patient who does not keep a scheduled appointment and does not notify the office to cancel
Ethics Branch of philosophy relating to moral standards
Etiquette A customary code of conduct, courtesy and manners
Biomedicine Advances in Medicine
Examples of Biomedicine Stem Cell Research, Life Support, Gene Therapy, IN-Vitro Fertilization
Principle of autonomy Right to make decisions about one’s own life
Principle of Beneficence Action of helping others and performing actions that result in benefit to another person
Principle of Nonmalfeasance “First Do No Harm”
Distributive Justice Principle by which a society or healthcare community decide to allocate resources that are in scarce supply. (Utilitarianism)
Advanced directive Making your wishes known in advance (in writing and verbally)
Living Will Document stating the desires of a person should he or she become incompetent because of injury or illness
Durable Power of Attorney Legal document establishing a person to make decisions for you
Healthcare proxy or agent A person elected to make decisions on behalf of another person in regards to healthcare
Uniform Anatomical Gift Act Right to choose Organ donation 18 Years and older
Minor A person under the age of 18
Mature Minor A person judged to be mature enough to understand the MD’s Instructions. Such a minor seeking medical care for treatment of drug or alcohol abuse, contraception, STD’s and pregnancy.
Emancipated Minor Person between the age of 15-18 who is either married, in the military or court emancipated.
Contract A voluntary agreement between two parties with the intent of benefiting each other.
Contract Law Addresses breach and neglect of legally binding agreement between two parties
Expressed Contract An agreement entered into either orally or in writing, everything must be clearly stated
Implied Contract Agreement shown through inference by signs, inaction or silence
Third party contract Contracts with insurance companies and outside vendors
Breach of Contract Either party fails to comply with the terms of the agreement
Abandonment Withdrawing medical care from a patient without providing sufficient notice
Boot Letter Releasing patient from practice properly
Fraud An intentional perversion of the truth
DEA Drug Enforcement Agency
FDA Food and Drug Administration
Medical Practice Acts Statutes that govern the right to practice in a State Vary from State to State
Medical Practice Acts Protects the health and safety of the general public
Medical Practice Acts Specify the rules and regulations for license renewal, suspensions and revocation
Good Samaritan Law State laws that protect healthcare professionals and ordinary citizens from liability in case of an emergency
Tort A civil injury, wrong act, committed against another person or property that results in harm and is compensated in money damages
Malpractice Negligence by a professional
Intentional Tort intentionally or deliberately injured by another
Unintentional Tort such as negligence- occur when the patient is injured as a result if the healthcare professionals not exercising the ordinary standard of care
Standard of Care Ordinary skills and care that must be used by all medical practitioners
Malfeasance Performing a wrongful or illegal act
Misfeasance Improperly performing an otherwise proper or lawful act
Nonfeasance Failure to perform a necessary action
Contributory negligence he patient has contributed to the injury
4 D's of Health Professionals Duty Dereliction Direct or proximate cause Damages
Duty The professional has a duty to the injured person
Dereliction Professional failed to meet that duty
Direct or Proximate Cause Continuous sequence of events, unbroken by any intervening cause that produces injury would not have occurred
Damages Injuries caused by defendant (Health Care Professional)
Special Compensation Monies owed due to loss of income
Discovery Rule Begins when problem is discovered
Statute of Limitations Amount of time someone has to file lawsuit
OSHA Occupational Safety Health Administration -Guidelines for workplace safety
CLIA Clinical Laboratory Improvement Amendments -Regulates all laboratories and ensures proper protocol is being implemented
Res ipsa loquitor- "The thing speaks for itself"
Respondeat Superior- "Let the Master Answer"
Subpoena Deuces Tecum "Under Penalty, Take with you" -Commands the doctor and the original medical record in court
Subpoena "Under Penalty" -Commands a witness to appear at a trial
Res Judicata The thing has been decided" -Decision already made by a judge/ binding
Deposition Oral or written testimony
Damages Injuries
Common or Case Law Established from court decisions -Made by judges when they apply previous court decisions to a current case. -Dependent upon interpretation of previous laws
Criminal Law Classified as Felony or Misdemeanors Penalties are fines, imprisonment or both
Administrative Law Branch of public law-regulations set by government agencies
Examples of Administrative Law Fraud -Health Department regulations -Licensing and supervision of controlled substances -Sets regulations against homicide, euthanasia, assault and battery
Non compos mentis "Not of sound mind"
Prognosis Prediction of the course of a disease
Assault The immediate threat of bodily harm
Battery Bodily harm, unlawful touching
Fraudulent Deceitful
Indictment A written charge presented to the court by grand jury against defendant
Stare Decisis "Let the decision stand"
Assumption of Risk A legal defense that prevents the plaintiff from recovering damages if the plaintiff voluntarily accepts the risk of activity (Consent Forms)
Affirmative Defense Allows the defendant (physician) to present evidence that the patients condition was the result of factors other than negligence
Denial Defense Plaintiff (injured) must prove the defendant (physician) did a wrongful, negligent act Jury must determine if the defendant caused the injury
Libel Written defamation of character
Arbitration The use of an arbitrator usually a retired judge to settle a dispute outside of court
Slander Spoken defamation of character
Risk management Identifying problem practices or behaviors, then taking action to control or eliminate them
Expert testimony Statement given concerning a scientific, technical, or professional matter by a person with authority regarding the matter, such as a physician
Consent form One-time signed document used to disclose personally identifiable health information for treatment, payment, or routine health care operations; not required by law
Medical Law Addresses legal rights and obligations that affect patients and protect individual rights (ie: rights of health care employees)
Applied ethics Practical application -- methods to identify morally correct actions
Civil law Private law that usually results in a payout/monetary compensation
3 questions to ask when deciding if something is ethical: Is it legal; is it balanced; how does it make you fell?
Grand jury Decides if there is enough evidence to send to trial; issues and indictment
Trial jury Determines innocence/guilt based on the evidence and testimonies
Examples of biothical dilemmas: Stem cell research; abortion; playing God; medical advancements (things you might be opposed to based on religious, personal, ethical beliefs)
Bioethics Moral issues and dilemmas that occur as a result of modern medical advancements
Relationship between Medical Law--Ethics--Biotheics Protect self, patient, employer -- also note that something might be unethical but not necessarily be illegal
Mediation Settling outside court
Constitutional law Addresses the relationship between individuals and their government (Amendments)
Statutory and Regulatory law Laws passed by legislative bodies, Congress or state
Doctor's defense against malpractice Affirmative defense (allows Dr. to present evidence) Denial defense (plaintiff must prove wrong doing) Expert witnesses (Dr. can bring professional witness to back up)
Folder Folded cover or container that holds records
Surname Individuals last name
Subject filing Alphabetical arrangement of records filed by topic or grouped under a main theme
Tab Projection above the body of a folder or guide; used for labeling
Tickler file Chronological file system that calls attention to future dates of appointments or business matters; a follow-up file that "tickles" the memory
Indexing unit Parts of a patient's name that has been separated into components (units) to be considered when filing
Alphabetic filing Arrangement of names in alphabetical sequence according to filing units
Lateral file Cabinet in which records are stored perpendicular to the opening of the file; also called vertical file
Encryption Encoding of computer data for security purposes, making data appear like gibberish to unauthorized computer users
Caption Name or number used in a filing system under which records are filed
Charge- out-system Procedure in a filing system provided to account for items removed from the files
Electronic files Collection of related data stored under a single title in a computerized system
Purge Procedure used in filing to remove outdated files or items from files, folders, or computer disks
Password Secret word, phrase, code, or symbol input for security purposes to identify the authorized computer user who wishes to gain access to the computer system
Backup Duplicate data file; equipment designed to complete or redo an operation if primary equipment fails
Association of Records Managers and Administrators (ARMA international) Nonprofit records management association organized to promote research and provide standardized filing guidelines
Diagnostic file Information based on the characteristics of a disease or illness learned from patient case histories and filed for reference
Virus Hidden program that enters a computer by means of an outside source, such as software, CD, or online services; can be harmless (flashing an on-screen message) or harmful
Binder file folder Document container with clamps for securing data
Numerical filing Arrangement of records in number sequence
Databases Collection of data (information) stored electronically
Guide Press-board sheet or metal divider used in a filing system to guide the eye to a section of a file and to provide support for records
Scores Creases along the lower front flap of a file folder that unfold to allow the folder to expand
Label Sticker used in filing that attaches to the file folder tab or other part of a folder; it may carry a caption or color code
Commercial filing system Customized guides and folders manufactured for professional office use
Download Process of transferring data (file or program) from a central computer to a remote computer
Cut Term used in filing to describe the size of the tab on the back of a file folder; usually expressed as a fraction, for example, one-half cut
Out Guide Manila sheet or folder inserted when a file is taken from a file drawer or cabinet to signal that it has been removed from the file; a substitution card
Downtime Period during which a computer is malfunctioning or not operating correctly
Open-shelf files Cabinets with horizontal shelves for record storage
Symptom Any indication of disease or disorder that is perceived or experienced by the patient; usually described in subjective terms, for example, depressed, confused, experiencing pain, or tired
Progress report Written observations made at examinations of a patient subsequent to an initial examination
Chief Complaint The main reason why a patient is being seen in the medical office
Medical Report Permanent, legal document in letter or report format formally stating the elements performed and results of an examination and treatment of a patient
Flow-Sheet One-page lists, charts, and graphs that allow the physician to quickly find medical information and perform comparative evaluations; used for medical data that is hard to track in narrative progress notes
SOAP Abbreviation for subjective complaints, objective findings, assessment of status to obtain diagnosis and implement a treatment plan; a method of structuring progress or chart notes
Laboratory Report Clinical record of the findings of physical and chemical analysis of specimens
Medical Report Written or graphic information documenting facts and events during the rendering of patient care
Audit Periodic examination or review of patient records to verify record-keeping, documentation for level of service billed, and proper medical care
Diagnosis Determination of the nature of a disease or injury
Ordering Physician Physician requesting non-physician services for a patient (e.g., diagnostic laboratory tests, pharmaceutical drugs, or durable medical equipment)
Case History Past and current information used in the evaluation process by the physician; part of the medical record
Prognosis Forecast of the outcome of a disease or injury
Source-Oriented Record (SOR) Common paper-based medical record management system that arranges documents according to sections
Attending Physician Medical staff member who is legally responsible for the care and treatment given to a patient
Electronic health record (EHR) practice management system Comprehensive computerized system that manages all aspects of the health record and the medical practice (e.g., appointment scheduler, accounts receivable, accounts payable, patient billing, health insurance claim submission, patients' medical records)
Health Information Management (HIM) A profession that concentrates on health care data and the management of health care information; Department of a hospital or large clinic that stores and manages medical records; Previously called medical records department; Health care professional
Treating or performing physician Provider who renders a service to a patient or completes a test
Electronic Health Record (EHR)- Computerized medical record system that has the capability to capture and store data in electronic form and to be transmitted to other health care locations
Consulting physician Provider whose opinion or advice regarding evaluation or management of a specific problem is requested by another physician
CHEDDAR Abbreviation for chief complaint, history, examination, details of complaints, drugs and dosage, assessment, and return visit; used as a format for charting
Referring Physician Physician sending a patient to another physician for the transfer of total or partial medical care. This term is also used loosely for a physician who sends a patient to a specialist for a consultation or for a diagnostic test
Acute Sudden onset of symptoms
Chronic Long term/ongoing symptoms or problem
Sign Indication of the presence or existence of a disease or body function disorder; objective evidence or observable physical phenomenon typically associated with a given condition
Problem-oriented medical record (POMR) Medical record keeping organizational system that contains data lists of the patients' permanent and temporary problems; each numbered and dated. Other lists are included, for example, medications, blood pressures, lab results, and surgeries.
X-ray report Written findings of an examination of a radio-graphic study on film
Past, Family and Social History Consists of Past history, Social history, childhood diseases/illness, family history
Created by: monkmaroni