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Module 1
Human Relations & Comm. 1 -- Chapters 1-9 (Final Review )
| Term | Definition |
|---|---|
| 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 |
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