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Chapter 1+2
Intro to medical assisting and the Health Record; Study Guide
| Term | Definition |
|---|---|
| Stage 1 learner | has a concrete reflective style of learning. Wants to know the purpose of the information and have a personal connection to the content. Considers information from many different point of views. They prefer to observe others and plan before taking action |
| Chain of Events map | displays the cause and effect of events, such as infection control or the history of medicine |
| Critical Thinking | a process of thinking that involves sorting out conflicting information, weighing knowledge about that information, ignoring personal biases, and deciding on a reasonable belief or action; An active search for the truth |
| William Harvey (1578-1657) | dicovered the circulatory sytem |
| Ignat Philipp Semmelweis (1818-1865) | the first physician to recommend hand-washing to prevent puerperal fever; believed there was a connection between performing autopsies and then delivering babies that caused puerperal disease in new mothers |
| Albert Sabin (1906-1993) | developed the oral live-virus vaccine for polio; 10 years after Salk discovered the first injected vaccine |
| Dr.Christian Bernard Procedure (1922-2001) | performed the first human heart transplant |
| D.O. | Doctor of Osteopathy |
| M.D. | Medical Doctor |
| Opthomologist | diagnose, treat, and provide comprehensive care for the eye and its supporting structures |
| CLIA | Clinical Laboratory Improvement Amendments. Regulatory standards that apply to all clinical testing performed on humans |
| Practioner | A health care provider who has aquired expert knowledge base, complex decision making skills, and clinical competencies for expanded practice |
| Hippocratic Oath | an oath of ethics historically taken by physicians, requires new physician to swear by anumber of gods to uphold specific ethical standards |
| Physicians Rights | the right to exercise personal and professional judgement in voting, speaking, and advocating on any matter regarding patient care, medical staff matters, or personal safety |
| A hospital inpatient | care provided in a hospital or other type of inpatient facility where you are admitted and spend at least one night or more depending on the condition |
| Morale | the mental and emotional condition of an individual or group with regard to the function or tasks at hand |
| Nurse Practioner | providers that give basic patient care services, including diagnosing and prescribing medications for common illnesses, or they may have additional training and expertise in a specialty area of medicine |
| AMT | American Medical Technologists. An organization founded in 1939 as a nationally recognized certification agency for multiple allied health professionals, including RMA, MLT, RPT, CMA, RDA |
| Osteopathic Physicians | use surgery and medicine in addition to osteopathic manipulative therapy in treating their patients |
| Inpatient Services | the care of patients whose condition requires admission toa hospital |
| Morale | the mental and emotional condition of an individual or group with regard to the function or tasks at hand |
| Professionalism | having courteous, conscientious, and respectful behaviors in the work environment |
| Prioritizing | designate or treat as more important than other things |
| Professional | has high ethical standards, displays integrity, completes work accurately and in a timely fashion |
| Uniforms | clothing and appearance that follows the employer and facilities dress code |
| Clinical MA | skills include assisting during physical examinations, performing patient screening, assisting with minor surgeries including sterilization procedures, performing ECGs, etc |
| Indirect Filing | numeric filing; one that requires the use of an alphabetic cross reference to find a given file |
| Aministrative MA | skills include answering the phone calls, managing the patient schedule, documenting accurately in a paper record and an EHR, creating and maintaining patient record, performing routine maintenance of facility equipment, etc... |
| Obstruction to professionalism | negative attitudes, procrastination, personal problems, gossip, personal communication, and dating co-workers |
| Population Health | providers and hospitals share information to have statistics on overall public health |
| Chief Complaint | concise amount of the patients symptoms, explained in the patients own words and describing why they came into the clinic |
| Indirect Filing | numeric filing; one that requires the use of an alphabetic cross reference to find a given file |
| Population Health | providers and hospitals share information to have statistics on overall public health |
| File: Jill Freeman M.D. | Freeman, Jill MD |
| Reasons to keep accurate medical records | critical to providing patients with quality care, ensuring accurate and timely payment for services furnished, mitigating malpractice risks, and helping health care providers evaluate and plan the patients treatment, and maintain the continuum of care |
| Medical Record Release | no information about a patient can be released to a third-party without the patients consent |
| Closed files | a file that hasnt been pulled or opened, or has been obliterated after 10 years |
| Physician owns what record | Health care records |
| correction to a medical record | verify the proper procedure, obliteration is never acceptable. Draw a line through the error, insert the correction in |
| How long until the minor reaches the age of majority | 18 years |
| Closed files | a file that hasnt been pulled or opened, or has been obliterated after 10 years |
| Purging | to completely destroy medcal records |
| corrections to a medical record | verify the proper procedure, obliteration is never acceptable. Draw a line through the error, insert the correction in a readable area, write "error" or "err." in the margins and write initials |
| SOAPIER | Subjective, Objective, Assessment, Plan, Intervention and Education, Revision |
| Voice Recognition | used to dictate progress notes, letters, emails, and any document in the facility that need to be created |
| EMR | Electronic Medical Record; owned by the individual |
| HITECH ACT | Health Information Technology for Economic and Clinical Health Act. Provided incentives for the meaningful use of certified EHR technology ot achieve health and efficiency goals |
| Query Based Exchange | the ability of providers to find or request information on a patient from other providers, often used for unplanned care |
| Health Records | easy storage for patient information, availibility to multiple users at the same time, a more efficient claim submission process |
Created by:
Wayne.Destiny
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