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MA150 final part 1

Delmar Chapters 4, 15, 18, 23, 25

trendelenburg used for shock patients
sim's vaginal or rectal exams; drape covers shoulders to the knees
prone posterior aspect of body including back or spine and legs; drape covers mid-chest area to legs
knee chest rarely used; proctologic exams and sigmoidoscopy procedures
fowler's table raised 45 or 90 degrees; cardiovascular or respiratory problems
lithotomy used for pelvic, proctoscopy, sigmoidoscopy exams
dorsal comfortable position for patients with back and abdominal problems; can be used for urinary catheterization; teen pelvic exams; diamond shape drape
supine (horizontal recumbent) exam of the anterior surface of the body; drape lap or waist down
manipulation flexion and extension of joints
mensuration process of measuring
auscultation process of listening directly to body sounds with a stethoscope
percussion process of eliciting sounds from the body by tapping
palpation exam of body using touch
observation or inspection general health, posture, body movements, skin, mannerisms, grooming
ataxia uncoordinated wide based walk
bruits abnormal sounds
cyanosis slightly blue or gray discoloration of skin
fenestrated drape covers patient from shoulder to knee
gait manner or style of walking
jaundice yellowing of skin
labyrinthitis inner ear infection
pallor lack of color or paleness
pyorrhea discharge of pus from the gums around the teeth
scleroderma a tight and atrophied skin
symmetry shape and size of body parts located on opposite side of the body
tinnitus ringing in the ears
vertigo dizziness
vitiligo white patches on the skin
charting rules black or blue ink, no spaces, no erasing, first initial, last name and title, correcting errors by crossing out entry and write "Corr" above entry. Red ink can be used corrected notation
POMR four major components database; problem list; diagnostic and treatment plan; progress notes
medical history form present health history; personal and family health history; social history; military service; body system questionnaire; medications; ROS
release of information form used to obtain medical records
privacy information form notice of privacy practice required to be given to all patients. 04/2004 HIPPA limits in which individuals protected health information (PHI) could be used or disclosed
demographic data form registers all the patients information which includes: DOB, SS#, insurance information, emergency contact, release of information signature
providers perspectives disease and successfully managing treatments, medications and procedures to control disease problems
patient perspectives the illness and management of illness
cross-cultural model important to understand that every patient interview is a cross-cultural one
preparing for the patient exam room is clean; all necessary supplies are available; review of patients chart - note the age
subjective known by the patient but cannot be seen by provider
source-oriented medical record (SOMR) traditional or conventional method of charting
SOAP/SOAPER subjective data: patients own words; objective; assessment; plan of treatment; education; response
problem-oriented medical record (POMR) more efficient way of keeping chart notes
objective can be seen, heard or measured by an observer
clinical diagnosis results with history, exam, and symtoms are determined
chief complaint "CC"; the problem that brings in the patient
CHEDDAR chief complaint; history; examination; details of problem; drugs and dosages; assessment; return visit
computerized health history two types: patient and provider generated; if patient doesn’t want to use, a face to face option must be given; completes during or after patient interview
language difficulty arrange interpreter prior to scheduling appointment
Refused to provide information charted as "patient refused"
medical health history includes personal data; CC; present illness - medications, allergies, other providers seen; medical history; family history; social and occupational history; ROS
characteristics of CC location; radiation; quality (describs the pain); severity; associated symtoms; aggravating factors; alleviating factors; setting and timing
location the place where the symptom is located
radiation how large an area the symtoms covers
quality characteristic of the symtoms
severity level and affects of pain
associated symtoms describe what other minor symtoms accompany the CC
aggravating and alleviating symtoms what makes the symtoms worse and/or decrease
setting and timing when the symtoms started and what happened when it started
allergies need to be noted in a readily visible part of the chart; a red sticker is commonly used
review of systems (ROS) performed during the physical exam and only the pertinent body systems will be reviewed
body systems  Cardiovascular, Digestive, Endocrine, Lymphatic, Muscular, Nervous, Reproductive, Respiratory, Skeletal, Integumentary (AKA skin), Urinary systems
medical chart a legal document which belongs to the provider
continuity of care record (CCR) developed by a number of medical groups (American Academy of Family Physicians and the American Academey of Pediatrics); improve continuity care, reduce errors, assure minimum standard that is shared with another provider
joint commissions journal on quality and patient safety reports that it is best not to use abbreviations
chart organization kept in chronologic order
insurance carriers role check codes for procedure and diagnoses agree; coverage in force at time of service; no pre-existing condition; no exclusions or restrictions
follow up on claims after a period of 4 - 6 weeks
common errors in completing claim forms typographic errors, incorrect information, all blanks completed, procedure with correct diagnoses, procedure medically necessary, no staples used
patient must do this sign authorization to release necessary medical information
pathology and laboratory codes begin in 8
radiology, nuclear medicine, diagnostic ultrasound codes begin in 7
surgery codes begin in 1 - 6; divides codes according to system
anesthesia codes begin in 01
evaluation and management codes begin in 99; every possible combination of medical facility visit
five-digit code for unlisted services the code ends in 99 and a special report must be submitted with an insurance claim form
CPT Manual issued every October; with 7 sections
V Codes used for anything not related to sickness or illness
up-coding also known as code creep, over-coding or over billing; deliberately billed a higher rate service than what was performed
Uniform Bill 04 (UB-04) a National Provider Identifier number must accommodate this form; standard form used for inpatient admissions, outpatient and emergency departments
unbundling codes separating the components of a procedure and reports them as billable codes with charges to increase reimbursement rates
Point of Service device (POS) electronic device
bundled codes grouping of several services that are directly related to a specific procedure and paid as one
claim register used to track claims filed
CMS-1500 (08-05) claim form accepted by most insurance carriers
current procedural terminology (CPT) developed by the American Medical Association (AMA) to convert commonly accepted descriptions of medical procedures into a five-digit numeric code
down-coding performed by insurance carriers if claims are ambiguous and reimburse the provider for the lowest possible fee
E codes injury or poisoning
encounter form provider completes for type of procedures used at time of service. Information from this form is translated onto the claim form
explanation of benefits (EOB) form sent to patient detailing charges allowed, amounts applied to deductibles, amounts not covered
Healthcare Common Procedures Coding System (HCPCS) developed by Medicare in 1983 as a supplement to the CPT system
ICD 9 CM developed by the WHO in 1977; classify all known diseases consisting of three-digit code with one or two numeric modifiers
M codes primarily used for cancer
modifier two-digit numeric number, used to provide additional information to insurance payers for procedures or services that have been altered
medicine codes begin in 9; cover immunizations, injections, dialysis, allergen, immunotherapy, chemotherapy, ophthalmologic, cardiovascular, pulmonary, and neurologist procedures
index comprehensive index listing every procedure alphabetically
ICD 9 CM - 3 volumes Volume I - tabular list; Volume II - alphabetic listing (used first when searching for an ICD 9 code); Volume III - procedures in tabular form
when coding do not guess; be precise; do not code what is not there
third party the insurance carries
Incoming mail directed to the appropriate personnel. Medical journals and advertisements are given to the provider; magazines and newspapers are placed in the reception area
four major styles of letters full block; modified block standard; modified block indented; simplified
accepted form letters thank referring providers; emphasizing patients criteria of care; announcement of new insurance; order supplies; acknowledging speaking engagement; reminder of payment due
notations "c" for copy; "pc" for photocopy; "bcc" - this is only used on the copy to the individual receiving a copy without the letters recipients knowledge
reference initials composer of letter in all caps; medical assistants initials in lowercase. Ex: WL:jg or WL/jg
styles of complimentary closure formal, general, informal
complimentary closing begins on the second line below the body of the letter
subject line keyed on the second line below saluation
saluation keyed flush with left margin, second line below the inside address
guidelines for letter placement margins may be 1, 1.5 or 2 inches; last line should end no less than 1 inch from bottom of page;do not divide the last word;minimum of three lines should be keyed on a second page; single space within paragraphs; double space between paragraphs
inside address keyed flush with left margin. *credentials appear after the providers name
spelling always check with in the dictionary for the correct spelling and read the definition
writing tips follow style and format set by provider; think about key points to be addressed; establish a tone of voice; use language the reader will understand; short sentences containing one idea
when writing correspondence is a reflection of the medical office
proofreading process of reading the document and checking for accuracy
proofreading tips read each document twice; prepare document, set it aside and proofread a third time later; do not proofread when tired; long documents, proofread in short intervals; have another staff member proofread
date line usually keyed on line 15 or two to three lines below the letterhead
full blocker letter most time efficient in ambulatory care
modified block standard all lines begin at the left margin except date line, closure, signature
simplified omits salutation and closure
optical character readers (OCRs) a scanner reads the zip code on the bottom line and prints a bar code in the lower right corner. Handwritten envelopes can not be read by the scanner
other types of correspondence memo-randum (memo), meeting agendas, meeting minutes
agenda specific items to discuss at the meeting
minutes a written record of what transpired during the meeting
postal classes first-class, periodical class (use to be second-class), standard mail, bulk mail, parcel post mail, media mail, priority mail, registered mail, express mail
Envelop common sizes 6 3/4, 7, 10
steps to building trust risk/trust, empathy, respect, genuineness, active listening
therapeutic communication cannot happen without taking into consideration the cultural and religious background
common bias or prejudice discrimination based on race or religion
common bias or prejudice prejudice related to sexual preference
common bias or prejudice choosing providers according to gender
common bias or prejudice preference for western style medicine
touch a powerful tool that communicates what cannot be expressed verbally
percentage of nonverbal communication 70%
percent of the tone 23%
percentage of the spoken word 7%
five C's in communication complete, clear, concise, cohesive, courteous
modes of communication speaking, listening, gestures, writing
feedback after the receiver has decoded the message sent
receiver recipient of the sender's message and decodes the meaning of the message
message the content being communicated
sender encoding or creating the message to be sent
communication cycle sender, message, receiver, feedback
undoing actions designed to make amends or cancel out inappropriate behavior
time focus attitude towards life: future, present, past
therapeutic communication adds an element of empathy
sublimation the channeling of a socially unacceptable behavior into a socially acceptable behavior
roadblocks close communication and prevent quality care of the total person
repression subconscious reaction, experiences temporary amnesia
regression an attempt to withdraw from an unpleasant circumstance by retreating to an earlier, more secure stage in life
rationalization the mind's way of making unacceptable behavior or events acceptable by devising a rational reason
projection means of defending against feelings or urges the person does not want to admit they are experiencing
prejudice an opinion or judgement that is formed before all the facts are known
perception conscious awareness of one's own feelings and the feelings of others
open-ended questions courages patient to provide additional information
active listening listening with a third ear. Being aware of what the patient is not saying or picking up on hints to the real message
bias a slant toward a particular belief
body language unconscious body movements, gestures, and facial expressions
closed questions answered with a simple "yes" or "no"
clustering grouping nonverbal messages into statements or conclusions
compensation substituting strength for a weakness
congruency between verbal and nonverbal communication. Don’t send mixed messages
cultural brokering the act of bridging, linking, or medicating between groups
culture a pattern of many concepts, beliefs, values, habits, and skills
decode interpet the meaning of the message
defense mechanism behavior that is used to protect the ego from guilt, anxiety, or loss of esteem
denial refusal to accept painful information
displacement the subconscious transfer of unacceptable emotions, thoughts or feelings
encoding creating the message to be sent
Abraham Maslow considered the founder of humanistic psychology .
hierarchy of needs 1. survival; 2. security; 3. love; 4. esteem; 5. self-actualization
high-context communication relies on body language, reference to environmental objects, and culturally relevant phraseology to communicate an idea
indirect statements elicit a response from a patient without feeling questioned
interview techniques knowing how to encourage the best communication
kinesics study of body language
low-context communication explicit and highly detailed language. In your face
masking attempt to conceal or repress the true feeling or message
personal space 1 1/2 to 4 feet
intimate space 1 1/2 feet to touching
social space 4 to 12 feet
public space 12 to 15 feet
facial expression most important and observed nonverbal communication
posture the manner in which we carry ourselves or pose in situations
finger tapping impatience, nervousness
Created by: karpati