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257 Cards in this Set

  • Front
  • Back

Clinical laboratory improvement and amendment CLIA

Sets quality standards an issues certificate for human clinical laboratories

Health insurance portability and accountability Act. (HIPAA).


The right to expect, review, and to receive a copy of your medical records and Billing records that are held by health plans and healthcare provider covered by the privacy rule.


Has 2 main purpose


1. To provide continuous health insurance coverage for workers who lose or change their job.


2. To reduce the administrative burdens and cost of healthcare by standardizing the electronic transmission of administrative and financial transactions and protects the patients personal medical information and confidentiality.


A CCMA cannot disclose any patient information unless authorized.


The joint commission

Regulated that correctly identifying patients is crucial to improving patient safety

Occupation safety and health administration (OSHA)

1. Federal agency that oversees and regulated safety in the workplace.


2. Training provided at no cost to the employee

Quality control (QC)

Promote accurate test results

Patient identification

1. Always ask patients to confirm their full name and date of birth


2. Never confirm patients name by speaking their name and date of birth to them. If they are not listening or hear they could say yes

Implied consent

1. Extending arm for phlebotomy.


2. Removing clothing for medical procedure or examination

Informed Consents

Information the patient of the risk, possible outcomes, and alternative therapies.

Written Contents

Much have a patients signature to perform the procedure.

Patient bill of rights,


A list of guarantee for those receiving medical care.

1. Patients have the right to a copy of the medical records.


2. Guarantees fair treatment


3. Autonomy over medical decisions and many more rights

Problem Oriented medical records (POMR)

Should always be filled out in chronological order

Patients have the right to view their medical records at any time

1. The information contained within the medical record belongs to the patient.


The physical form where the information is house belongs to the author

CMS-1500 Center for Medicare and Medicaid service

Basic standard claim form used by healthcare professional to request reimbursement for services provided to patient

Encounter form or superbill

An itemized form of services submitted to insurance carriers for reimbursement of rendered services, A CCMA Would also use this form to check patient out after an office visit

Release of information form

Allow patient access to his own medical records and allows the patient control over to whom those records are released

Preferred provider organization (PPO)

Managed care organization of providers, hospitals, other healthcare providers who have a greed with an insurer or a third party administrator to provide health care at reduced rate to the insurer

Medicaid

Provide health insurance for the medically needy

Medicare

Federal insurance plan covers of the age of 65 and Oder or have paid into the system through payroll tax

Tricare

Healthcare for military personnel and their independence to receive care from civilian providers at the expense of the Federal government

Workers Compensation

Wage replacement and medical benefits for those injured on the job

Advance beneficiary notice (ABN)

Waiver of liability, is a notice a provider should give you before you receive the service

Copay

Specific sum of money based on their patients insurance policy benefits due at the time of service

Coincidence

An amount a policyholder is financially responsible for according to their insurance policy. Policyholders must meet a specified amount before the insurance company will pay their portion.

Modified

Indicate one procedure was use multiple times on a patient

Scheduling.



Advance booking. making an appointment for patient in advance.


Clustering. seeing patients on the same day at the same time.


Double booking. two patients are given the same appointment time.


Hard of hearing or deaf patients. get an interpreter.


Late provider. offered to reschedule a patient’s appointment if the provider is late.

New patience NP. a patient who had not been seen by the provider before Or who has not been seen in three or more years is considered a new patient for coding and billing purposes.


No show ns. patients who have missed their schedule appointment.


Tests. schedule the least invasive test first if a patient is having multiple tests.


Wave schedule. three or four patients are scheduled every half hour and or seen in the order in which they arrive in the office.

Aerophagia

Swallowing air

Alopecia

Sudden increased hair loss

Anthropometric

Used to assess the size, shape, and composition of the human body e.g BMI or a growth chart

Chief complaint cc

The primary symptom that a patient states as the reason for seeking medical care

Cirrhosis

Chronic liver disease

Cholecystectomy

Removal of the gallbladder

Dysuria

Painful or difficult urination

Coinsurance

An amount a policyholder is financially responsible for account to their insurance policy. The policyholder must meet amount before the insurance company will pay their portion

Dextrocardia

The heart points to the right side instead of the left

Electronica health record EHR

Electronica record of patient’s health related information and can be created, manage, and access from multiple healthcare organization


Also always back up the information on the storage device

Electronica medical record EMR

Electronica record of patient’s health related information and can be create, manage, and access within a single health care organization


Also always back up the information on storage device

Hemostasis

Promote coagulation and stops bleeding

Hypoglycemia

Low blood sugar that can be helped by giving the patient orange juice

Cardiologist

Diagnoses and treats disease of the heart

DO doctors of Osteopathy

Similar to medical doctors, but have a holistic approach.

Endocrinologist

Treats patients who suffer from hormonal imbalances.


Treats diabetes, thyroid disorders, pituitary disorders, and other hormonal disease

Deductible

Specific amount of money a patient must pay out of pocket before the insurance carrier begins paying for the servers in a calendar year

Explanation of benefits (EOB)

A statement detangling what service were paid, denied, or reduce in payment by the patient insurance company

Preauthorization

A decision by your health insurance or plan that healthcare service, treatment plan prescription drugs, or durable medical equipment is medically necessary

Percertification

The process of obtaining eligibility, certification or Authorization and collecting information from the health plan prior to the impatient admissions and selected ambulatory procedure and service

Referral

The process of directing or redirecting to a medical specialist or agency for definitive treatment

Vilification of eligibility

Before your provide care, it is important to confirm how patient will pay for service. It is equally important to verify a patient’s insurance eligibility before you provide any care

CPT

Current procedural terminology

ICD

International classification of diseases


Each diagnostic and procedural code allows for submission of service for reimbursement from insurance companies and to provide statistics data for research studies

Nurse practitioners NP

Advanced academic training beyond the registered nurse RN

Orthodontist

Concerned with correction of deformities or functional impairment of the skeletal system

Pathologist

Study cause and effect of disease, perform autopsies, and analyze tissue sample

Physician’s assistant

Practice medicine under the direction and supervision of a licensed medical doctor MD

Radiology

The science dealing with x-rays and other high energy radiation, especially the use of such radiation for the diagnosis and treatment of disease

Dorsal recumbent

Lying flat on the back with knees bents

Radiology

The science dealing with x-rays and other high energy radiation, especially the use of such radiation for the diagnosis and treatment of disease

Fowlers

Upright sitting position with the exam table raised to a 90 degree angle


Best position to help patient who have difficulty breathing

Dorsal recumbent

Lying flat on the back with knees bents

Lithotomy

Lying flat on the table with buttocks at the end of the table and feet resting in stirrups

Dorsal recumbent

Lying flat on the back with knees bents

Prone

Lying flat on the abdomen with the arms above the head

Supine

Lying flat on the back with the arms down to the side


1. Used for doing an EKG


2. Measuring an infant


3. Any procedure that requires a patient to be lying on their back

Sim (lateral)

Lying on the left side with the leg slightly flexed and the right leg flexed at a 90 degree angle


Exams involving the rectum and administrating enemas

Trendelenburg

Legs elevated above the head to force circulation to vital organs.


Effective in raising a patient’s low blood pressures.

Coronal/frontal

Divides the body into anterior and posterior section.

Sagittal

Divides the body into left and right

Transverse

Divides the body into top (superior) and bottom (inferior) party

Body mass index BMI

Calculate by height and weight

Cardiopulmonary resuscitation CPR

100 compression should be performed in one minute

Eye irrigation

To relieve inflammation and discomfort

Figure eight bandage

Typically used to wrap the ankle

Ischemic

Restrictions of oxygen rich blood to a portion of the body

Parathyroid hormone

Hormone secreted by the parathyroid glad that is important in bone growth


Associated with the regulation of calcium in the body.

Patient centered care

Requires the inclusion of both family and patient regarding the patient care

Pericarditis

Inflammation of the pericardium (surrounding lining of the heart)

Personal protective equipment PPE

Equipment that protects the wearer from bodily injury or infection.


OHSA mandate that PPE be free of charge

Petechiae

Broken capillaries due to bleeding under the skin. One reason is too tight a tourniquet

Pyelonephritis

Inflammation of the kidney which can cause pain in the lower and mid back.

Retinopathy

Disease of the retina that results In impairment or loss of vision and can be complication of diabetes mellitus.

Vertigo

Episodes of dizziness and sensation of spending with the certain head movements.


1. Caused by an inner ear disorder


2. Can be caused by performing an ear irrigation on a patient.

SOAP note

A format for communicating important patient information in a chart in an organized manner


Subjective. information the patient conveys


Objective. measurable information about the patient (vitals, diagnostic findings, ect)


Assessment. a detailed examination by the provider to determine health status.


Plan. a series of proposed intervention to improve health or treat disease.

Vertigo

Episodes of dizziness and sensation of spending with the certain head movements.


1. Caused by an inner ear disorder


2. Can be caused by performing an ear irrigation on a patient.

Spirometey

Common office test used to assess how well your lugs work by measuring how much are you inhale, how much you exhale, and how quickly you exhale


1. Requires two maneuvers.

Vertigo

Episodes of dizziness and sensation of spending with the certain head movements.


1. Caused by an inner ear disorder


2. Can be caused by performing an ear irrigation on a patient.

Spirometey

Common office test used to assess how well your lugs work by measuring how much are you inhale, how much you exhale, and how quickly you exhale


1. Requires two maneuvers.

Syncope

Fainting which can exhale as dizziness, lightheadedness and ringing in the ears

Spirometey

Common office test used to assess how well your lugs work by measuring how much are you inhale, how much you exhale, and how quickly you exhale


1. Requires two maneuvers.

Transition of care

Refers to the coordination and continuity of health care during a movement of a patient from one healthcare setting to another or to home.

ABGs

Arterial blood gases

Cbc

Complete blood count

CC

Chief complaint

Dys

Difficult, painful

-Ectomy

Surgical removal

itis

Inflammation

Nephe/o

Kidneys

Ology

Study of

Ophth

Eye

Oto

Ear

PE

Physical examination

R.O.M

Range of motion

STI

Sexually transmitted infections

UA

Urinalysis

BP

Blood pressure

CXR

Chest x Ray

Derm

Skin

CABG

Coronary artery bypass graft

I and O

Intake and output

K

Potassium

NS

No show

O2

Oxygen

OTC

Over the counter

Plasty

Surgical reconstruction

PO

By mouth

STAT

Immediately

TB

Tuberculosis

UTI

Urinary tract infection

Infant head measurement

Place tape measure at the most prominent part of the forehead, often one to two fingers aboveboard the eyebrows.

Ishihara eye chart

Test for color vision

Pulse oximetry

Measuring the oxygen level in the blood


Place on fingers or ear lobe

Streptococcus test

Collected from the throat (oral)

Stress test

Monitor cardiovascular capacity during a period of increasingly strenuous exercises while the patient is using a treadmill.


Patient sweating is normal test should be continued with no interruption

Transferring a patient

Is always a concern so as not to injure the patient or the healthcare worker


Always use correct body mechanics, like bending at the knees when lifting

Vision test

Visual acuity chart that is used to test distance visual acuity. It use capital letters of different size to test vision on the literate adult. The test is conducted from 20 feet away

Weighing a patient

Perform quality control QC on a scale by balancing the scale first before weighing a patient

Wound care

Always clean in a circular motion from inward to outward


If a wound culture is taken, then include in the documentation any recent patient use of antibiotics

Standard precaution

Set of infection control practices used to prevent transmission of disease.


Basically treat everyone as if they are infected

Transmission Methods

1. Airborne, influenza, measles, tuberculosis


2. Blood-borne, human immunodeficiency virus (HIV)


3. Contact, sexually transmitted illnesses (STIs)

Ophthalmoscope

Used to examine and see inside the structure of the eye.

Otoscope

Used to look into the ear

Sphygmomanometer

Is an Instrument used to measure blood pressure

Weighing

If a patient is having difficulty standing then have them use a walker by placing the walker over the scale

Anatomy

The study of the structure of living things

Physiology

Function and processes of living organism

Red blood cell, erythrocyte, RBC

Transports oxygen throughout the body.

Platelets, thrombocytes

Function is to stop bleeding by clumping and clotting vessel injury

White blood cell, leukocyte, wbc

Cells of the immune system that are involved in protecting the body.


Least prevalent of these are basophils comprising less than 1% of white blood cells.


Neutrophils account for roughly 60% of white blood cells.

Caution

1. Gloves should always be worn if there is a risk of exposure to bodily fluids such as urine, blood, cysts, pus, ets


2. Sharps container A hard plastic container that is used to safely dispose of needles and other sharp objects. Always log removal in a facility logbook

Sharps container

A hard plastic container that is used to safety dispose of needles and other sharp objects. Always log removal in a facility log book.

Sharps container

A hard plastic container that is used to safety dispose of needles and other sharp objects. Always log removal in a facility log book.

Crohns diseases

A type of inflammation bowel disease.


Has an underlying genetic cause; provider should screen for family history.

Sharps container

A hard plastic container that is used to safety dispose of needles and other sharp objects. Always log removal in a facility log book.

Crohns diseases

A type of inflammation bowel disease.


Has an underlying genetic cause; provider should screen for family history.

Graves disease

An autoimmune disease that affects the thyroid. Smoking may increase the risk of disease and may worsen eye problems.

Sharps container

A hard plastic container that is used to safety dispose of needles and other sharp objects. Always log removal in a facility log book.

Crohns diseases

A type of inflammation bowel disease.


Has an underlying genetic cause; provider should screen for family history.

Graves disease

An autoimmune disease that affects the thyroid. Smoking may increase the risk of disease and may worsen eye problems.

Illness

Subjective departure from wellness.

Sharps container

A hard plastic container that is used to safety dispose of needles and other sharp objects. Always log removal in a facility log book.

Crohns diseases

A type of inflammation bowel disease.


Has an underlying genetic cause; provider should screen for family history.

Graves disease

An autoimmune disease that affects the thyroid. Smoking may increase the risk of disease and may worsen eye problems.

Illness

Subjective departure from wellness.

Influenza

A common viral infection that can be deadly, especially in high risk groups.


Body aches, sore throat, coughing, fever, runny nose, and feeling tired.

Pharmacology

The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties.

Pharmacology

The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties.

Antipyretics

Medication used to lower a patient body temperature

Pharmacology

The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties.

Antipyretics

Medication used to lower a patient body temperature

Absorption

How long it takes for a drug to get into the bloodstream.

Pharmacology

The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties.

Antipyretics

Medication used to lower a patient body temperature

Absorption

How long it takes for a drug to get into the bloodstream.

Contraindications

A specific situation in which a drug should not be used because it may be harmful to the patient.

Pharmacology

The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties.

Antipyretics

Medication used to lower a patient body temperature

Absorption

How long it takes for a drug to get into the bloodstream.

Contraindications

A specific situation in which a drug should not be used because it may be harmful to the patient.

Distribution

The reversible transfer of a drug from one location to another within the body.

Pharmacology

The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties.

Antipyretics

Medication used to lower a patient body temperature

Absorption

How long it takes for a drug to get into the bloodstream.

Contraindications

A specific situation in which a drug should not be used because it may be harmful to the patient.

Distribution

The reversible transfer of a drug from one location to another within the body.

Excretion

The removal of a medication from the body.

Pharmacology

The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties.

Antipyretics

Medication used to lower a patient body temperature

Absorption

How long it takes for a drug to get into the bloodstream.

Contraindications

A specific situation in which a drug should not be used because it may be harmful to the patient.

Distribution

The reversible transfer of a drug from one location to another within the body.

Excretion

The removal of a medication from the body.

Indication

A condition which makes a particular treatment or procedure advisable.

Pharmacology

The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties.

Antipyretics

Medication used to lower a patient body temperature

Absorption

How long it takes for a drug to get into the bloodstream.

Contraindications

A specific situation in which a drug should not be used because it may be harmful to the patient.

Distribution

The reversible transfer of a drug from one location to another within the body.

Excretion

The removal of a medication from the body.

Indication

A condition which makes a particular treatment or procedure advisable.

Metabolism

Most important organ for drug metabolism is the liver.

Pharmacology

The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties.

Antipyretics

Medication used to lower a patient body temperature

Absorption

How long it takes for a drug to get into the bloodstream.

Contraindications

A specific situation in which a drug should not be used because it may be harmful to the patient.

Distribution

The reversible transfer of a drug from one location to another within the body.

Excretion

The removal of a medication from the body.

Indication

A condition which makes a particular treatment or procedure advisable.

Metabolism

Most important organ for drug metabolism is the liver.

Bronchodilator

Dilates the bronchi and bronchioles by decreasing resistance in the respiratory airway and increasing airflow to the lungs. Should stop using before a patient is scheduled for a pulmonary function test.

Pharmacology

The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties.

Antipyretics

Medication used to lower a patient body temperature

Absorption

How long it takes for a drug to get into the bloodstream.

Contraindications

A specific situation in which a drug should not be used because it may be harmful to the patient.

Distribution

The reversible transfer of a drug from one location to another within the body.

Excretion

The removal of a medication from the body.

Indication

A condition which makes a particular treatment or procedure advisable.

Metabolism

Most important organ for drug metabolism is the liver.

Bronchodilator

Dilates the bronchi and bronchioles by decreasing resistance in the respiratory airway and increasing airflow to the lungs. Should stop using before a patient is scheduled for a pulmonary function test.

Enteric Coates tablets

Contain an outer shell that prevents an oral tables from dissolving until reaches the intestines, often to prevent stomach irritation.

Pharmacology

The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties.

Influenza vaccine

Must document expiration date and lot number in patient medical record.

Antipyretics

Medication used to lower a patient body temperature

Absorption

How long it takes for a drug to get into the bloodstream.

Contraindications

A specific situation in which a drug should not be used because it may be harmful to the patient.

Distribution

The reversible transfer of a drug from one location to another within the body.

Excretion

The removal of a medication from the body.

Indication

A condition which makes a particular treatment or procedure advisable.

Metabolism

Most important organ for drug metabolism is the liver.

Bronchodilator

Dilates the bronchi and bronchioles by decreasing resistance in the respiratory airway and increasing airflow to the lungs. Should stop using before a patient is scheduled for a pulmonary function test.

Enteric Coates tablets

Contain an outer shell that prevents an oral tables from dissolving until reaches the intestines, often to prevent stomach irritation.

Pharmacology

The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties.

Influenza vaccine

Must document expiration date and lot number in patient medical record.

Opiates

Drugs with morphine like effects, derived from opium to treat pain.

Antipyretics

Medication used to lower a patient body temperature

Absorption

How long it takes for a drug to get into the bloodstream.

Contraindications

A specific situation in which a drug should not be used because it may be harmful to the patient.

Distribution

The reversible transfer of a drug from one location to another within the body.

Excretion

The removal of a medication from the body.

Indication

A condition which makes a particular treatment or procedure advisable.

Metabolism

Most important organ for drug metabolism is the liver.

Bronchodilator

Dilates the bronchi and bronchioles by decreasing resistance in the respiratory airway and increasing airflow to the lungs. Should stop using before a patient is scheduled for a pulmonary function test.

Enteric Coates tablets

Contain an outer shell that prevents an oral tables from dissolving until reaches the intestines, often to prevent stomach irritation.

Pharmacology

The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties.

Influenza vaccine

Must document expiration date and lot number in patient medical record.

Opiates

Drugs with morphine like effects, derived from opium to treat pain.

Non-steroidal anti-inflammatory drug


(NSAID)

Reduces pain and inflammation.

Antipyretics

Medication used to lower a patient body temperature

Absorption

How long it takes for a drug to get into the bloodstream.

Contraindications

A specific situation in which a drug should not be used because it may be harmful to the patient.

Distribution

The reversible transfer of a drug from one location to another within the body.

Excretion

The removal of a medication from the body.

Indication

A condition which makes a particular treatment or procedure advisable.

Metabolism

Most important organ for drug metabolism is the liver.

Bronchodilator

Dilates the bronchi and bronchioles by decreasing resistance in the respiratory airway and increasing airflow to the lungs. Should stop using before a patient is scheduled for a pulmonary function test.

Enteric Coates tablets

Contain an outer shell that prevents an oral tables from dissolving until reaches the intestines, often to prevent stomach irritation.

Pharmacology

The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties.

Influenza vaccine

Must document expiration date and lot number in patient medical record.

Opiates

Drugs with morphine like effects, derived from opium to treat pain.

Non-steroidal anti-inflammatory drug


(NSAID


Reduces pain and inflammation

Transdermal patches

Adheres to patients skin and the medication is absorbed slowly. Instruct the patient to write the date and time on each patch that is applied.

Antipyretic

Medication used to lower a patient body temperature

Absorption

How long it takes for drug to get into the bloodstream.

Contraindication

A specific situation in which a drug should not be used because it may be harmful to the patient.

Distribution

The reversible transfer of a drug from one location to another within the body.

Excretion

The removal of a medication from the body.

Indication

A conditioner which makes a particular treatment or procedure advisable.

Metabolism

Most important organ for drug metabolism is the liver.

Bronchodilator

Dilates the bronchi and bronchioles by decreasing resistance in the respiratory airway and increasing airflow to the lungs. Should stop using before a patient is scheduled for a pulmonary function test.

Enteric Coated Tablets


Contain an outer shell that prevent an oral tablet from dissolving until it reaches the intestines, often to prevent stomach irritation.