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Medical Assistant
| Question | Answer |
|---|---|
| Medical Terminology and why its important | - universal language in the clinical world, allows for conscise communication and quick notes. |
| Acronym + give an example | - Using the first letter of a word to help with memorization or concussing info. |
| Abbreviation + give an example | - Using the short form of a word |
| Greek and Lation roots | - allows for more meaning to be added to a word without using different words. U can use prefix, root, and sufix |
| -ae | -pronouced as eye |
| -ii | -pronouced as "ee-ee" |
| SOB | -"short of breath |
| BUN | - "B-U-N" |
| AIDS | - Acquired Immunodeniceny syndrom |
| Ac | - Acute |
| prn | - pro re nata, means as needed |
| A-fib | - Atrial fibrillation |
| BMI | -Body mass index |
| Ca^2+ | - Calcium |
| dys | - bad or diffcult |
| meno | mensutral |
| rrhea | flow |
| rhino | nose |
| anthropo | man |
| when obtaining paitien history what do we need to collect? | Identifying data, CC, HPI, PMHx, FHx, SHx, |
| What is the protocol when getting ur patine history? | Making sure to verify, making sure theyre not a poor historian, WIRTING down everything, crossing out instead+ instails and date |
| CC | - chief complaint, why are they here |
| HPI | - History of present illness, builds on the CC by describing what happedn. U can use the 1 attributes and wong baker |
| 7 attributes | - Locations, Quality, Qunitity or Severity, Timing, Setting, Remitting, Associated manifestations. |
| Wong Baker | - scale of 1-10 |
| PMhx | - Past Medical Histry, previous or current medical illness and conditions, hospitizations, etc |
| FHx | - family hisoty, only imidate family, revelant health of family relevant to the CC |
| SHx | - Social history, background info on who that are their day to day life , drugs, smoking, also tough questions. |
| How should smoking be recorded? | - # of pack per day *years of smoking |
| ethical considerations that need to be followed at all times | - nonmaleficence, Beneficence, Automny, Confidentiallity |
| Contents of Paitent charts | Patient info Financial info Privacy Agreement Info release MHx Forms / Medical survey Patient intake Diagnostic results Treatment Plans Copies of Medication prescription Info from other providers Progress notes Administrative notes |
| Methods of charting+ what is each one | - SOMR(source oriented medical record), POMR(problem oreinted medical record, this one is most common) |
| Progress notes | - summarization of clinical visit, there are 2 ways SOAP/SOAPER or CHEDDAR. |
| CC | - chief complaint, why are they here |
| HPI | - History of present illness, builds on the CC by describing what happedn. U can use the 1 attributes and wong baker |
| 7 attributes | - Locations, Quality, Qunitity or Severity, Timing, Setting, Remitting, Associated manifestations. |
| Wong Baker | - scale of 1-10 |
| PMhx | - Past Medical Histry, previous or current medical illness and conditions, hospitizations, etc |
| FHx | - family hisoty, only imidate family, revelant health of family relevant to the CC |
| SHx | - Social history, background info on who that are their day to day life , drugs, smoking, also tough questions. |
| How should smoking be recorded? | - # of pack per day *years of smoking |
| ethical considerations that need to be followed at all times | - nonmaleficence, Beneficence, Automny, Confidentiallity |
| Contents of Paitent charts | - |
| Methods of charting+ what is each one | - SOMR(source oriented medical record), POMR(problem oreinted medical record, this one is most common) |
| Progress notes | |
| SOAP/SOAPER | -most common way |
| CHEDDAR | |
| Physical Examination | - Preformed by the doctor, there are 2 types: Diagnostic exam: regarding the CC Genreal exam: looking for thigns the patient might not be aware of |
| Diagnostic methids | Auscultations(listening), Percussion(tapping), Visual inspection, Palpation(touching and feeling) |
| EHR | -electrionic health record, that can be patient generated of provider generated. |
| paper charts | - had to be kept for 10 years from the date the patient was last seen or if paiten was deceased they were kept for 5 years |
| Fomite | Comtaminated stuff. |
| Where can infections occur from? | direct contact, air born, bodily fuilds, non living surfaces. |
| Biohazardous waste | Waste that might be infected or inffectious |
| Bohazard container | these are for sharps and any instrucment that might pose the risk of pucntiing the skin |
| PPE | -personal protective equipment, this is worn to protect against mircoorganisms. - osha also requires proper PPE at no cost, proper education about it, and proper disposal or cleaning or it. |
| Gloves | - Considered standard precaution , shoudl be changed between every patient, arent biohazard waste until visibly soiled. |
| Masks | - should be worn over respitoryy openings |
| respirators | - are nessicary for certain cases, may cover the entire face or respitory openings |
| Different types of PPE | Gloves, masks, respirtaors, gown, eyewear, face shelids |
| gown | - should be worn whenever there is a risk of transmission by surface |
| eyewear | - should be worn if there is a risk of transmission thru eyes |
| face sheild | - protecting the whole face |
| Hand washing + when | - the best wasy to prevent diesases - before and after patinets, ppe, going on break or touching urself |
| hand sanizters___ | should not be used as a subsititue, let it fully dry |
| Contaminated with blood | - anti bacterial soap, then 50 isopropyl or ethyl alchol air dry for 60 sec, then was hands again |
| isolation procedures | - a patinet is either at an increased risk to themselves and others , always wear standard PPE and the required ones |
| Strict islolation | - spread via air or direct contact, private room and bathroom, must wear gown mask and gloves, equimpent must be left in room - example: measals, staph infection |
| droplet isolation | -spread via droplets of mucous, private room but can leave room wearing mask, wear mask and gloves - example: pertusis, meningitis |
| Blood and Body fuild preaution | - spread via body fuild, private room sometimes private bathroom, gloves, other ppe if risk of splattering - Dysentery, HIV |
| Respiratory isolation | - Transmitted through exhaled praticles, private room, gloves N95 respirator - Tuberculosis, whopping cough |
| Contact Isolation | - spread through direct contact, private room, gloves and sometimes gown, , medical equiment is dedicated to that patient - skin, wound infection |
| Reverse Isolation | - Susceptible to infection, dependinf on the paitinet ppe and other stuff might be different, - transplant, burn victims |
| Safety violations | Must always be reported to ur supervisor |
| OSHA | - Occupational Safety and Health Administration - this is a federal agencey under teh deparment of labor, their job its to set guideline for workplace safety anf employment training. |
| MSDS | - Material saftey department sheet has information about each of the chemical used in the faciality must be accebile to all emplyees by OSHA - provides treatment for exposure |
| DOH | - Department of health is a state level agency rhat regulat healthcare facitlies conditions through state licensure and by enforcing fedral certification rules. |
| FDA | - Food and drug administration, fedral agency that overseas the regulation of drug and the clain made by phamaceuticle companies. |
| CDC | - The center of disease control and prevention is a federal agency under the department of health and human servcices tht is responsible for monitoring occupational saftey and health and providing education and standards for public health. |
| HHS | - Department ofHealth and Human services is a federal level agency that administers programs intended to contribute to the health and well being of americans \ - medicare, medicade, CDC |
| Posion control center | - exposure to chemicals that are not on the MSDS - 1-800-222-1222 |
| J-Co | - Joint Commission is independant not for profit organization. acredits and certifes more than 21,00 healthcare organizations. They can shut down ur organization . |
| BBP | - Blood born pahtogens are infection micro organisms. in blood that can cause disease in humans - examples: HBV, HCV, HIV, AIDS |
| OSHA BBP standard | - Establish a control plan that is annually updating with implemantion of precaution with control in place, PPE is provided, make HBV vaccine avalible, post exposure evalution, labels and sign to communitcate hazards, training. |
| OSHA PPE standard | - This it to prevent BBP incidents, the level and type of protection must fit the expected exposure, must also be accisable, disposing and decontaminating the PPE must be done in the proper way. |
| OSHA sharps standard | - Sharps are things that can penetrate the skin and cause BBP , OSHA makes sure that employees are safe. - Employers are required to have safer medical devices, do prompt disposils, have a sharps container, and proper handeling of the containners. |
| OSHA BBP exposure standard | - if there is an exposure it must be reported to a employer immeditaly , medical evaltuon, followup , and employee should be provided a wirtion opion. |
| Code black | bomb threat |
| Code blue | cardiac arrest |
| Code grey | Disaster |
| Code red | Fire |
| Code Orange | Hazardous material |
| Code Pink | Child abdution |
| Code white | OB Hemorrhage |
| Code green | Violent behavior |
| Code silver | controlled access |
| Fire extingusher protocall | - PASS , pull the pin, aim at the base of the fire, squezz the trigger, sweep side to side |
| Eye washing | - wash skin with anti bacterial soad, flush the area for at least 15 mins, tell a superviosr and they much document it. |
| Vital signs | - medical assitants jobs, it is important we gert the correct value so the doctor can make a accurate diganosis. U must ask the patient for consent before touching them, if they say no then u can just take note of that. |
| Implied consent | - not a verbal consent. |
| factors affecting vital signs | - activity level, body size, emotional state, bioloical sex, age, drugs/medications, illness |
| Pluse sites | - Temporal, carotid, apical, rachial, radial, femoral, popliteeal, dorsalis pedic, posterior tibialis |
| BPM adult range | 60-100 |
| BPM newborn to 1 month | 70-190 |
| BPM 1 month to 11 month | 80- 160 |
| BPM 11 month to 2 years | 180-130 |
| Volume | the force of each pulsation, reveals heart strength and vessels conditions - week/thread-y, normal, full bounding |
| Oximetry | - measures the concentration of oxegen in the blood, pluse oximetery probes only responde to pulsutation in the cappliars: finger, ear, toe. Anything 95%+ is normal,95% should be reported to the doctor |
| Temperature measurement C to F | C*9/5+32=f |
| Temperature measurement F to C | (f-32)*5/9=C |
| Oral Temperatures | - taken inside the mouth using a disposable strpe or digital,normal temp is 98.6 F |
| Aural Temperture | - taken inside the ear using a tympanic thermometer measuring the infrared wave in the tympanic membrane. not comfortable for children under 2, normal temp: 98.6 F |
| Temporal artery thermometers | - Used on patients forehead and most commonly used in pediatric setting, 99.4-99.6 f |
| Rectal and axillary | - butt and underarm, 99.6f and 97.6f respectively |
| Collecting weight adult | - u can use electronic scale or balance scale, ask them to remove shoes and not hold on to external things for support |
| lbs to kg | #lbs / 2.2=#kg |
| BMI | height, weight, age |
| Collecting height infant | - wash hands, child needs to be barefoot, place child on paper table, mark at head and feet, measure distance and record measurment |
| collecting weight infant | - child should be fully naked, tell parents to take off everything, measure in pounds and ounces |
| Pressure | - the amount of force applied to an area spefic space |
| Hemodynamic | - Describes the properties of blood as it flows through the vascular system. The speed, turbulence, and diameter of the vessel and viscosityt of the blood are all the study of hemodynamics |
| Compressibility | - Describes the ability of a substance to resist changeds in pressure the substance expreses exteranlly |
| Systoli Pressure | - the pressure inside the heart and aorta which the cardiac muscle is contracting maximally |
| diastolic pressure | - the pressure inside the arterial vascular system at the point the heart is maximally relaxed |
| Why is monitering blood pressure important | - An enlarged heart will limit cardiac blood supply and th heart will begin to fail as it becomes starved of nourishment. |
| where is BP taken and why | - Left arm(heart is on the left side), upper arm (at the level of the heart), brachial artery (good diameter) |
| what are some issue that could arise from cuff for bp? | - A short cuff: false high reading - a narrow cuff:false high reading - a arm above the heart :lower reading - a arm lower:false high reading |
| when should u not measure bp? | - IV, hemodialytic fistula, scarring |
| HTN | - Hypertension is a highblood pressure dieseas it can be modifired with deit and excercise. longstanding HTN can result in heart faliure. |
| Collecting BP | - Correct size cuff, place on artery mark 2.5 inches above the fold, cuff is inflated till the pulse is no longer felt +40mmHG, slowly deflate at 2-3 mmHG, first sound is systolic and last sound is diastolic. |
| Krotkoff sounds+ how many phases are there | - Sounds are produced as the arterial walls distend after they have been compressed by the inflated bp cuffs, there are 5 pahses |
| Phase 1 | - Clear sharp sound, first sound, systolic - 120 |
| Phase 2 | - softer swishing sound - 120-110 |
| Phase 3 | - Distinc sharp tapping -110-100 |
| Phase 4 | - often used as the diastoclic for children - 100-90 |
| phase 5 | - diastolic -90-80 |
| Orthostatic Hypotension | - condition in which the patient bp drops when changing position, usally dehyadrated or anemic patients experience this. just need to lie down and check bp - <100mmHg - <70 mmHg |
| Normal bp | <120/80 |
| Elevated bp | SYS: 120-129 DIA: <80 |
| Stage 1 bp | sys: 130-139 dia:80-89 |
| Stage 2 bp | sys:140> dia:90> |
| Hypertensive crsis | sys:180> dia:120> |
| Respiration + how to take it | - sound be measured without making paitent aware, count the number of breaths for 30 mins and * 2 |
| Normal adult Respiration | 16-20 BPM |
| Normal late childhood Respiration | 16-26 BPM |
| Normal early childhood Respiration | 20-40 BPM |
| Normal newborn/infancy Respiration | 30-80 BPM |
| Spirometery | -Peak flow meter, used to measure the muscluar effort to exhale forcibly from fully inflated lungd and the elastic recoil of the lungs to diagnose for current and future treatment. Normal values depend on patient. |
| what is the spirometery used for | - asthma, chronic bronchitis, emphysema, COPD |
| Head circumference, infant | wash hands talk to infant reassure them start with tape abouve the eyebrows and hold in place circle around head, abouve the ears read to the nearest 1/2in or .1 cm record value |
| Chest circumfrance, infant | wash hands talk to infant dont measure until they are breathing properly measure bare chest, nipple line record |
| Chest circumfrance, adult | measure one inhaled and 1 exhaled |
| Snellen eye chart | - normal 20/20 eye vison test, before starting ask them to take out lens and if they are comfotable reading english language. |
| How to do eye test | verify explain what they will do stand 20 feet from chart cover left eye but dont close it, read smallest line give one min to readjust same for right eye record as fraction, top-feet away from chart/bottom-number of smallest line read |
| Ishihara test | - to see if color blind there are 24 series of pictures |
| PCP | primary care provider |
| COC | -Continutiy of care |
| TOC | -tranistion of care the movement of patient from onne setting of care to another. If MAs arent doing their job correctly or any health providered a lot can be lost with this move ment |
| Patient centered care | - is the practice of caring for a patient as well as their family memebers, this can be done by empowring them to advocate for themselves |
| What are the 8 Hardvard medical school for patient care | Respect for patient coordination and integration of caare eduation physical comfort emotional support involvment of family continuity and transtion access to care |
| AIDET | - simpler version of 8 principles with actions Acknowledge introduce duration explaintion thank you |
| What are the 7 transition intervention categories | Medication managment transition planning patient and family engaement of education information transfer follow up care healthcare provider engagement shared accountabillity across provideres |
| Encounter form | - also known as the super bill, contains a detailed reciept of healthcare services |
| What are the main parts of a super bill | Providers info patients info service info addtional info |
| What other forms are used for billing | - CMS-1500, UB-04 |
| CMS-1500 | - Also known as HCFA 1500, standard paper clain form to bill medicare . |
| UB-04 | - Also known as CMS-1450, form designed for billing insitutional providereds, this have revenue codes. |
| Financial responsibility | - outlines a written consent for the provider affie to attempt to bill the patients insurace carrier for services, provider must haave a copy of insurance card, without this they should treat patients as self payers |
| ABN | - Advanced beneficiary notice of non coverage , is for medicare patients that allow that patient to ackowledge consent to have testing performed with the knowledge that medicare may or may not pay |
| ABN potentional non coverage | - does not pay, if , based on ur condition, done to frequently, experimental or research purposes. |
| Explain the 3 options on ABN | pg. 91 |
| PCP | - primary care provider, oversees a patient care and COC |
| explain the proccess of ording imaging and ordering diagnostic test | - pg.92 |
| POP | - pg.92 |
| - Preferred Provider Organization (PPO) | - type of health insurance plan managed care based. Meaning providereds have come together and offering discount services. Tend to be more expensive however more flexiable too. Dont require referal but piror authorization |
| - Health Maintence Organization (HMO) | - provides services with own network, requires referals, co-pay for spealist will be at higher than for PCP if deductiables arent met. Preventative exams are fully covered or low price, experimental arent covered, |
| Medicade | - Health insurance plan provided by the state and federal government for either low income or disabled person. The patient will have a case worker. No age limit. can be co insured with medicare |
| What does medicade offer | his plan covers, hospt, home healht,hospice, nursing home, drugs, doctor visits, medical equipment. |
| Medicare | - Health insurance provided federal governemnt for the people who are 65+ and have disabilites. |
| What are the 4 parts of medicare and explain each one | pg.93 |
| explain the process of referals | pg.94 |
| Controlled substance act | - Ministered by the Drug enforcment Administration and the us department of justice. The act lists controlled drigs in five catergories for potential abuse and dependance. |
| What does the controlled substance act require | - code of federal regulation, watches those who adminiter, prescribe, and dispense any drugs listed. All must renew their registration every 3 years. |
| How is the controlled substance regulated? | If u administer those drugs u must keep record. Inventory must be taken every 2 years and record must be kept for 2 years. |
| Good samaritan Law | - written and enforced in all states, they are in place to protect trained professionals , they do not apply to medical professionals on duty |
| HIPPA | - Health insurance portability and accountablity act, used to establish national standard for elctronic health care transaction under HHS, "identifiable health information to be protected with privacy and secuirty standards". |
| PSDA | - patient self determination act, federal law, requires that facilites give a patient the option of providing an advanced directive to be kept on file. |
| Uniform anatomical gift act | - donor |
| Informed consent | - Paitnet is told the risks and benefits of all treatments, have the opportunity to question, and take time , and give their decsion, and evidence of signage |
| The patients bill of rights | Right to information , choice of providers and plan, acces to emergency services, taking part in treatment decisions, respet, privacy, complaints and appeals, responsibility, other bills. |
| AMA | - Against medical advice, paitent is remvoing themselves care aginst medical advice. |
| LWBS | - left without being seen, paitnet are were not see but they were in the wating room but left before they could be seen by the provider. u must chart this |
| NS | - No show, paitent didnt show up to appointment, also chart |
| What are things in the MA scope of practice | Pg. 303 |
| What are things outside MA scope of practice | pg. 303 |
| Living will | A written record of the type of medical care the patient would want in specifc circumstances. |
| Health care proxy | a form that gives someone else the right to make medical decsions for them if they are unable to |
| Advanced directive | - mix of health care proxy and living will |
| Power of attorny | - a document that makes somone the legal decison maker for them. |
| MOLST | - Medical orders for life sustaining treatment, a program for end of life patients to get care that alines with them |
| Procedure manual | - Operations manual, derailed info about clinical and adminstrive tasks |
| 3 methods of referal | -, regualr, urgent, STAT |
| Regular referain | takes up to 2 weeks to approve |
| Urgent referal | take about 1 to 2 days to approve |
| Stat referal | takes that second to approve |
| Prior authorization | - used to authorize payment from an insurace company to a medical facility |
| Reuisiton | - shows what tests a doctor is ordering in order to demonstrate medical nesscity when it is time for the patient or insurance to pay for the tests |
| Memorandum | - letter used to notify emplyees of the work place |
| Medical coding | - the act of assigning a code to a billable item inorder to classify and charge for it |
| CPT | - Current Procedural Terminology, code are published by the American Medical Association, US uses 4th edition they were designed to provide a uniform data set that could be used to decribes medical service |
| ICD | -Internal classification of disease, is the standrd internatioal system of clasying mortaliy and morbity statistics, used to define disease |
| ICD-10CM | - currently used for codes |
| v-code | - used in ICD-9 usde to classify occansions and circumstances other than disease or injury the result in a provider-encounter. |
| z-code | - same as v code, ICD-10 |
Created by:
dmeraj35