Chapters 1/2 Flashcards

Intro to medical assisting and the health record

1
Q

Stage 1 learner

A

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

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2
Q

chain of events map

A

displays the cause and effect of events, such as infection control or the history of medicine

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3
Q

critical thinking

A

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

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4
Q

William Harvey

A

discovered the circulatory system

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5
Q

Ignat Philip Semmelweis

A

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

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6
Q

Albert Sabin

A

developed the oral live-virus vaccine for polio; 10 years after Salk discovered the first injected vaccine

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7
Q

Dr.Christian Bernard Procedure

A

performed the first human heart transplant

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8
Q

D.O.

A

Doctor of Osteopathy

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9
Q

M.D.

A

Medical Doctor

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10
Q

Opthamologist

A

diagnose, treat, and provide comprehensive care for the eye and its supporting structures

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11
Q

CLIA

A

Clinical Laboratory Improvement Amendments. Regulatory standards that apply to all clinical testing performed on humans

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12
Q

Practioner

A

A health care provider who has aquired expert knowledge base, complex decision making skills, and clinical competencies for expanded practice

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13
Q

Hippocratic Oath

A

an oath of ethics historically taken by physicians, requires new physician to swear by a number of gods to uphold specific ethical standards

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14
Q

Physicians Rights

A

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

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15
Q

A hospital Impatient

A

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

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16
Q

Morale

A

the mental and emotional condition of an individual or group with regard to the function or tasks at hand

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17
Q

Nurse Practioner

A

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

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18
Q

AMT

A

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

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19
Q

Osteopathic Physicians

A

use surgery and medicine in addition to osteopathic manipulative therapy in treating their patients

20
Q

Professionalism

A

having courteous, conscientious, and respectful behaviors in the work environment

21
Q

Impatient services

A

the care of patients whose condition requires admission toa hospital

22
Q

Prioritizing

A

designate or treat as more important than other things

23
Q

Professional

A

has high ethical standards, displays integrity, completes work accurately and in a timely fashion

23
Q

Uniforms

A

clothing and appearance that follows the employer and facilities dress code

24
Q

Clinical MA

A

skills include assisting during physical examinations, performing patient screening, assisting with minor surgeries including sterilization procedures, performing ECGs, etc

25
Q

Indirect Filing

A

numeric filing; one that requires the use of an alphabetic cross reference to find a given file

26
Q

Administrative MA

A

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…

27
Q

Obstruction to professionalism

A

negative attitudes, procrastination, personal problems, gossip, personal communication, and dating co-workers

28
Q

chief complaint

A

concise amount of the patients symptoms, explained in the patients own words and describing why they came into the clinic

29
Q

indirect filing

A

numeric filing; one that requires the use of an alphabetic cross reference to find a given file

29
Q

File: Jill Freeman M.D.

A

Freeman, Jill MD

29
Q

population health

A

providers and hospitals share information to have statistics on overall public health

30
Q

Reasons to keep accurate health records

A

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

31
Q

Medical Record Release

A

no information about a patient can be released to a third-party without the patients consent

32
Q

closed files

A

a file that hasnt been pulled or opened, or has been obliterated after 10 years

33
Q

physicians own what record?

A

Health care records

34
Q

correction to the medical record

A

verify the proper procedure, obliteration is never acceptable. Draw a line through the error, insert the correction in

35
Q

how long until a minor reaches age of majority

A

18 years

36
Q

purging

A

to completely destroy medcal records

37
Q

SOAPIER

A

Subjective, Objective, Assessment, Plan, Intervention and Education, Revision

38
Q

voice recognition

A

used to dictate progress notes, letters, emails, and any document in the facility that need to be created

39
Q

EMR

A

Electronic Medical Record; owned by the individual

40
Q

query based exchange

A

the ability of providers to find or request information on a patient from other providers, often used for unplanned care

40
Q

HITECH Act

A

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

41
Q

health records

A

easy storage for patient information, availibility to multiple users at the same time, a more efficient claim submission process

42
Q
A