material which should never be used to correct medical records
white out
person who can legally sign a release of medical records
patient or guardian
a system of organizing information in a medical record
SOAP
medical charts are usually filed in which order
alphabetical
each page of the medical record should include
patients name and date
information in the medical record is
private and confidential
records for patients currently receiving treatment are in the
active files
chart notes should be complete
daily
each patient is assigned a number in this system
numerical filing
a patient must sign this document to obtain past records
records release form
which of the following names would be filed first: Pittman, Phillips, Pham, or Phipps
pham
which of the following names would be filed last: Larsen, Lamar, Lai, or Larson
Larson
which of the following numbers would be filed first: 073291, 036689, 157623, or 064942
036689
a fund used for small office purchases is called
petty cash
a term for overpayment on an account is a
credit
monthly fee for bank account is a
service charge
what is an encounter form?
preprinted statement listing codes for basic office charges
what is a post?
entering charges and payments to a patients account
what is aging schedule?
list of unpaid accounts by date of service
what is debit?
another term for charge
what are adjustments?
correction to a patients account
what is endorsing?
placing the practice name and account number on the back of the check
what are accounts payable?
total of bills owed by the practice
what are accounts receivable?
total of all patients accounts
who can you never accept a payment from?
a patient who has been turned over to a collection agency
what is a deductible?
portion of bill patient is required to pay each year
what is a write off?
cancellation of an unpaid debt
what is a copayment?
amount patient must pay for each office visit
what is medicare?
federal insurance program for elderly persons or persons with permanent disabilities
what is a crossover?
term for an insurance claim for a medicare and MediCal patient
what is workers compensation?
type of insurance for work related injuries
cysto-
bladder
what is the term for narrowing?
stenosis
Gastrectomy is the term for excision of the
stomach
the abbreviation meaning two times a day is?
bid
which is the correct spelling? pharengytis, pharengitis, pharyngytis, or pharyngitis
pharyngitis
a trained medical assistant is able to - function as a nurse, interpret lab results, administer IV therapy or assist with minor procedures
assist with minor procedures
a patients photo was made public without her permission. This is called - invasion of privacy, defamation, fraud, or slander
invasion of privacy
patient instruction sheets are used to
prevent misunderstanding
the best time to perform a breast exam
monthly
communication with patients can be improved by
providing privacy
hyper-
increased
nephro-
kidney
auto-
self
osteo-
bone
dys-
painful
litho-
stone
brady-
slow
chole-
gallbladder
macro-
large
gastro-
stomach
arthro-
joint
tachy-
fast
thoraco-
chest
hypo-
decrease
mammo-
breast
veno-
vein
hepato-
liver
hemo-
blood
ophthalmo-
eye
trans-
through/across
-oma
tumor
-algia
pain
-ectomy
surgical removal
-itis
inflammation
-ology
study
-emia
blood condition
-tomy
incision
-osis
abnormal condition
-megaly
enlargement
-graphy
xray exam
-phasia
speech
-scopy
examination
-gram
record
-ptosis
falling, dropping
-stasis
stopping
-plegia
paralysis
-desis
bind or tie
-phagia
swallowing
-ostomy
surgical opening
-pathy
disease
hs
at bedtime
IM
intramuscular
Hx
history
q.i.d.
four times a day
gtt
drop
q.d.
once daily
p.c.
after meals
OD
right
CC
chief complaint
CHF
congestive heart failure
RLQ
right lower quadrant
Dx
diagnosis
LMP
last menstrual period
I & D
incision and drainage
Tx
treatment
hct
hematocrit
LUQ
left upper quadrant
SOB
shortness of breath
po
by mouth
hypotension
low blood pressure
cicatrix
scar tissue
nephromegaly
enlargement of the kidney
cholelithiasis
gallbladder stones
subcutaneous
beneath the skin
maxilla
upper jaw
goiter
endocrine system disease
hematemesis
vomiting blood
capillary
smallest blood vessel
patella
kneecap
neuritis
inflammation of the nerve
myocardial infarction
heart attack
hematuria
blood in the urine
large tongue
macroglossia
syncope
fainting
cystogram
xray study of the bladder
bradycardia
slow heart beat
pleura
membrane covering the lungs
osteoporosis
loss of calcium in the bones
pruritits
severe itching
anterior
situated in front or in the forward part
distal
remote, farther from the point of origin
proximal
nearest, closer to the point of origin
peripheral
situated toward the outer part
inferior
situated below or directed downward
extension
straightening motion that increases the angle between adjoining bones
adduction
movement toward the midline
superficial
situated near the surface
ventral
pertaining to the belly
lateral
away from the midline, pertaining to a side
dorsal
pertaining to the back
medial
pertaining to the middle
superior
situated above or directed upward
plantar
referring to the sole of the foot
flexion
bending motion that decreases the angle between adjoining bones
prone
lying flat on the back
where are the lungs found?
thoracic cavity
supine
lying flat on the back
caudal
toward the tail
where is the liver found?
abdominal cavity
a physician retires without notifying his patients. The physician could be charged with
abandonment
the disposal of medical infectious waste is controlled by
CAL/OSHA regulation
a physician describes a procedure, risks and alternative treatment to a patient. this is called a
informed consent
a medical assistant who performs a procedure ordered by the physician employer is protected under what principle?
respondeat superior
a medical assistant can be required to appear in court with this document
subpoena
narcotic prescriptions are regulated by witch agency?
drug enforcement administration
a medical assistant discusses a patient by name at lunch with others in the building. The M.A. could be charged with
invasion of privacy
a patient agrees to receive a flu shot. this is an example of
consent
a method of mediating disputes between a patient and physician is called
arbitration
patient rights include this principle
confidentiality
a false statement harmful to another persons character is called
slander
a person under legal age who is self supporting and living apart from parents is called a
emancipated minor
this document is required in order to provide medical records
records release
failure to perform professional care is called
negligence
state law requires that physicians always report this condition
abuse
billing an insurance company for false charges is considered
fraud
the patients medical records belong to the
physician
the best method of preventing transmission of disease is
hand washing
the artery normally used for taking a pulse reading is
radial
an instrument used to examine the ears
otoscope
social history includes the
marital status
which of the following occurs as a urine specimen remains on the counter for a long time?
bacteria multiply
a holter monitor measures heart
rhythm
the nerve most apt to be affected during an injection in the buttock is the
sciatic
an injection into fatty tissue lying immediately under the skin is called
subcutaneous
the first and most important rule to remember in an emergency is to
stay calm
medical assistants are expected to make decisions in medical office emergencies based on their
medical knowledge
a surface free of contaminated instruments
sterile field
gloves masks and gowns are known as
person protective equipment
washing instruments to remove debris
sanitization
absence of bacteria
asepsis
bacteria that thrive in oxygen
aerobes
an organism that produces disease
pathogen
molds and yeasts are types of
fungi
instruments touched by ungloved hands are
contaminated
destruction of all microorgansisms
sterilization
how should hinged instuments be when sterilized?
open
a sterile pack containing scissors, thumb forceps and gauze squares is called a
suture removal pack
the term for removal of contaminated materials from a wound is
debridement
scrubbing the surgical site in a circular motion from the center of the edge is
surgical prep
removing fluids or gasses by suction is called
aspiration
flushing out a wound or cavity with a solution is called
irrigation
a sterile surface containing sterile items is a
surgical tray
S/s, s/b and b/b describe surgical
scissors
instruments used to clamp off blood vessels are called
hemostats
a sterile covering placed over a wound is called a
dressing
instruments such as fiberoptic scopes are soaked in chemicals in a procedure called
cold sterilization
pulse located at the elbow
brachial
pulse located on the knee
popliteal
pulse located at the thumb site of the wrist
radial
pulse located at the side of the neck
carotid
pulse located in the middle of the groin
femoral
the highest reading of blood pressure is called
systolic
blood pressure measured while patient is lying, sitting or standing
orthostatic
an instrument used to test reflexes is
percussion hammer
an instrument used to open a body orifice for viewing is
speculum
an instrument used to examine the eye is
ophthalmoscope
an instrument used to examine the ear is
otoscope
an instrument used to examine the rectum and colon is
sigmoidoscope
irregular heart rhythm
arrhythmia
rapid pulse
tachycardia
having no symptoms
asymptomatic
slow pulse
bradycardia
material status is considered
social history
the patients own words determine the
chief complaint
family history is considered
subjective
the physicians physical examination is considered
objective
physical, chemical and microscopic examinations are
urinalysis
a chemical substance that prevents clotting of blood in a blood specimen
heparin
a vacutainer that contains no anticoagulant has a stopper colored
red
material that presents a risk of possible infection
biological hazard
the first step in preparing a laboratory specimen
patient identification
the usual site for capillary testing is
fingertips
urine specimen obtained by the patient simply urinating in a cup is called
random catch
patient is instructed to cleanse the urethra with an antiseptic towelette is a
clean catch
legal method of documenting lab testing process security
chain of custody
a sterile swab would be used for a
wound culture
the intensity of color in a urine specimen indicates
concentration
improper handling of lab specimens can result in
contamination
instrument used to prepare urine or microscopic examination is
centrifuge
the standard EKG consist of how many leads?
12
simple laboratory test with a high degree of accuracy
waived test
quality control in the laboratory ensures what kind of results?
accuracy
stool specimens are tested for
occult blood
a machine used for testing lung capacity
spirometer
tuberculosis can be diagnosed from a
sputum specimen
patient begins urinating in the toilet and catches the remainder in the cup is a
midstream catch
a physician orders 1500 mcg of vitamin b12. you have 1000 mcg/ml on hand how many milliliters will you give?
1.50
a physician orders 10 mg of compazine. you have 5 mg/ml on hand. how many milliletes will you give
2 ml
a subcutaneous injection is given at an angle of
45 to 90
the most used deep (adult) intramuscular injection site is the
dorsogluteal
when administering a subcutaneous injection, the amount of the dose should no exceed
2cc
when choosing a needle/syringe unit, you should keep in mind the patients
age and size
the gauge of a needle is determined by the diameter of its
lumen
a physician orders 0.250 mg of lanoxin. you have 0.125 mg tablets on hand. how many tablets will be given?
2
what is the preferred site for a tuberculin skin test?
anterior forearm
the proper way to express 1/2 cc is
0.5 cc
an injection into fatty tissue lying immediately under the skin is called
subcutaneous
medication given p.o. is administered
orally
an ampule contains how many doses?
1
antitussive medications are used to control
coughing
all procedures during a medical emergency must be
documented
the first technique to use to control bleeding is
direct pressure
poorly reacting pupils might indicate a severe
head injury
a piece of emergency equipmentused to reestablish normal heart rhythm
defibrillator / AED
the first thing a medical assistant should do in an emergency situation is
assess the situation
equipment prepared in advance for emergency use is called a
crash cart
a basic CPR is to clear the
airway
the lack of a pulse is one way to identify
cardiac arrest
a straight fracture across the bone shaft is called a
transverse
a weak and rapid pulse is a sign of
shock
a severe involuntary contraction of muscles is called a
seizure
an overdose of insulin would cause the patient to go into
diabetic shock
nitroglycerin is ordered for chest pain. it will be administered
under the tongue
formation of blisters following a burn can be treated with
cool water
an emergency tray would include
epinephrine
to establish an airway, the patient would be places
on the back
symptoms of heart attack including pain in the chest
jaw or arm
the procedure used for a choking person is
Heimlich maneuver
a broken bone wedged into another bone is called an
impacted fracture
a patient who is having a seizure should never be
restrained
what are the ABC's of emergency care?
airway, breathing, and circulation
you should first establish a patients responsiveness by asking
are you okay
if the patient is unresponsive the medical assistant must determine if the patient is
conscious
the next step would be to activate the
emergency response system by calling 911
check the carotid pulse and if present
continue rescue breathing 10 to 12 breaths per minute
to open the airway, the patient should be places on the
back the head tilted and the chin lifted
PPE supplies for CPR include
disposable gloves and CPR ventilator mask
during CPR, fingers are placed at the point where the
sternum and the ribs join
adult compression ratio
30:2 both one and two man hands with two hands
children compression ratio
30:2 both one and two man hands with one hand
infants compression ratio
15:2 two man hands with 2 fingers
in CPR the depth of a compression should be for adults
1 1/2 to 2 inches
in CPR the depth of a compression should be for children
1 to 1 1/2 inches
in CPR the depth of a compression should be for infants
1/2 to 1 inch
when preparing envelopes, one should use
capital letters in block format
telephone calls should be answered no later than the
third ring
a patients fails to keep an appointment. the medical assistant should make a note on the
patients chart
a backup tape for a computer is used to
copy hard drive information
which name would be filed first in an alphabetic filing system?
Wilson Babcock
CPT codes are used to identify a
medical procedure
ICD-9 codes are used to identify a
medical diagnosis
patient insurance cards should be reviewed
at each visit
an HMO is an example of what kind of healthcare?
managed
a good tool for reminding staff when certain things need to be done is called a
tickler file
information may be sent rapidly by using a
fax machine
the process of arranging a series of printed pages is called
collating
the most important part of preparing correspondence
proofreading
a daily log should be kept of all
incoming telephone calls
incoming mail should be sorted and
date stamped
the preferred way to send valuable items by mail
registered mail
termination of care letters should be sent by
certified mail/ return receipt
system for leaving messages which can be retrieved later is
voice mail
cancelled appointments should be noted in the
patients chart
a method of maximizing appointment time is
wave scheduling
the appointments schedule can be used as a
legal record
a useful telephone service for a physician with 2 office
call forwarding
on a multi-line telephone, the line in use will be indicated by
steady light
to best utilize the appointment schedule, set aside time for
call backs
an important way to make the patient feel comfortable
warm greeting
missed appointments can be reduced by
calls to confirm appointments
patients should be notified of any
unusual delays
having the patients chart at hand is necessary when
scheduling procedures
first come first served" method of appointment scheduling
open hours
stating names within another patients hearing could be
breach of confidentiality
the physical equipment of a computer is called
hardware
computer hardware with permanent memory
hard disk
a portable memory storage device is called a
floppy disk
important procedure for protecting hard disk information
backing up
the term used for starting the computer
boot
flashing line showing where data can be entered
cursor
the most common device for data imput
keyboard
word processing allows the user to quickly move or delete blocks of
text
a convenient feature used when proofreading a document
spell check
large group of files used for information retrieval is
data base
all medical office should have a security policy to protect
patient information
computerized patient accounts simply monthly statements and
insurance billing
computer scheduling allows quick access to
open appointments
this list can be easily prepared with computer scheduling
daily appointments
a computer field contains a piece of
information
software program that quickly calculates numbers
spreadsheet
rearrangement of information in a database is called
sorting
setting margins and tabs for a letter is called
formatting
no office should download information from the internet without a
anti-virus program
a method of controlling access to confidential patient information
passwords
progress notes are usually filed in what order?
chronological
the medical record belongs to the
physician
the document stating patient agrees to a procedure
consent
a method which speeds the filing process
color coding
the term for removing inactive records from the files
purging
chart notations require the date,
information and initials
what is a paper claim?
insurance claims which have greater chance for rejection
what is a modifier?
addition to a procedure code which indicates special circumstances
what is medi-gap?
a policy which supplements medicare coverage
what is tricare/CHAMPUS?
insurance coverage for military dependents
what is CMS-1500?
the universal claim form
an insurance claim with incomplete information will be
rejected
what is capitation?
monthly fee a provider is paid for each covered patient
what is explanation of benefits?
insurance company statement of how a claim is settled
what is fraud?
billing services the physician did not perform
a procedure code followed by the modifier -99 indicates
multiple modifiers
what are electronic claims?
insurance claims which shorten the payment cycle
what is a clean claim?
term for an insurance form that has been filled out correctly
when should a patients addresses and billing information be updated?
each visit
insurance claims require a patient to sign what to release information?
authorization
an assignment of benefits form allows the insurance company to
pay the provider
What is HIPAA
federal law protecting privacy of health insurance information
what are HCPCS codes
medicare supplement to the CPT procedure codes