Chapters 1/2 Flashcards
Intro to medical assisting and the health record
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
discovered the circulatory system
Ignat Philip Semmelweis
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
developed the oral live-virus vaccine for polio; 10 years after Salk discovered the first injected vaccine
Dr.Christian Bernard Procedure
performed the first human heart transplant
D.O.
Doctor of Osteopathy
M.D.
Medical Doctor
Opthamologist
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 a number 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 Impatient
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
Professionalism
having courteous, conscientious, and respectful behaviors in the work environment
Impatient services
the care of patients whose condition requires admission toa hospital
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
Administrative 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
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
File: Jill Freeman M.D.
Freeman, Jill MD
population health
providers and hospitals share information to have statistics on overall public health
Reasons to keep accurate health 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
physicians own what record?
Health care records
correction to the medical record
verify the proper procedure, obliteration is never acceptable. Draw a line through the error, insert the correction in
how long until a minor reaches age of majority
18 years
purging
to completely destroy medcal records
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
query based exchange
the ability of providers to find or request information on a patient from other providers, often used for unplanned care
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
health records
easy storage for patient information, availibility to multiple users at the same time, a more efficient claim submission process
