Important Things A CMAA Should Know 1

A Certified Medical Administrative Assistant must know these topics:

Integumentary Vocabulary
1. Albino: deficient in melanin (pigment)
2. Collagen: Structural protein found in the skin and connective tissue
3. Melanin: Major skin pigment
4. Lipoctye: Fat Cell
5. Macule: discolored, flat lesion, freckles, tattoo marks
6. Polyp: benign growth extending from the surface of the mucous membrane.
7. Fissure: groove or crack-like sore
8. Nodule: solid, round or oval elevated lesion more than 1 cm. in diameter
9. Ulcer: Open sore on the skin or mucous membranes
10. Vesicle: small collection of clear fluid; blister
11. Wheal: smooth, slightly elevated edematous (swollen) area that is redder/paler than the surrounding skin
12. Alopecia: baldness
13. Gangrene: death of tissue associated with loss of blood supply
14. Impetigo: bacterial inflammatory skin disease characterized by lesion, pustules, and vesicles

Common Medical Record Abbreviations
ALL: allergy
BM: bowel movement
bx, bi: biopsy
CA: cancer
CC or cc: chief complaint
CNS: central nervous system
CXR: chest x-ray
DNR: do not resuscitate
Dx: diagnosis
ENT: ears, nose, throat
Ex, CPX, PE: exam, examination
FH: family history
f/u: follow-up
GI: gastrointestinal
HPI: history of present illness
Hx: history
N/O: no complaints
PERRLA: pupils equal/round/reactive to light
PH: past history
PT: physical therapy
Px: prognosis
R: respiration
ROM: range of movement
ROS: review of systems
Rx, Tx: treatment, prescription
SH: social history
SOB: short of breath
Sx: symptoms
UA: urinalysis
VS: vital signs
WNL: within normal limits
w/o: without

Telephone Message
- Name of person whom the call is for
- Date and time of call
- Name of individual calling
- Caller's phone number they wish to be reached at
- Detailed reason for call, if caller wishes to leave reason
- Action required (call back, Rx refill, etc.)
- Initials of person taking the message

Contents of Medical Record
- Personal Demographics
- Medical History
- Progress Notes
- Encounter forms/superbills
- Radiology Reports
- Laboratory Reports
- Consultations
- Med Sheet including allergies
- Hospital Discharge Summaries
- Consent and disclosure forms
- Insurance authorizations and referrals

Making a Handwritten Correction in the Medical Record
- Draw a line through the error
- Write 'error' or 'corr.' and initial in margin including date and time
- Insert the correct immediately after the error
- Never use white out, black marker, or eraser on errors
- Do not hide errors, bring to the attention of provider if it could affect patient's health and well-being

Record Maintenance
- Always verify correct medical chart has been pulled
-  Mend chart as necessary
- File documentation in a timely manner
- Make sure required forms are kept up to date
- Verify patient information periodically

Retention of Records
- Laws regarding retention vary from state to state
- 10 years or length of time on statute of limitations
- Minors: 3 years after age of majority
- Medicare/Medicaid patient: a minimum of 6 years
- Deceased patient: 2 years

Classification of Records
- Active: Currently receiving treatment
- Inactive: Not seen for 6 months
- Closed: Moved, terminated, or deceased

Types of Files
- Drawer files
- Shelf files
- Rotary circular files
- Lateral files
- Compactable files
- Automated files

Filing Supplies
- Chart covers or folders
- Labels: color coded, alpha and numeric
- OUTguides
- Special notation labels: allergies, same name, copays, primary care physician

Filing Procedures
- Conditioning
- Releasing
- Indexing and Coding
- Sorting
- Storing and Filing

Conditioning Files
- Mending damaged records
- Removing pins, paper clips, brads, staples
- Stapling related papers together

Releasing Files
Indication that the record is ready to be filed
- Signature
- Initials
- Date
- Stamp

Indexing and Coding Files
- Deciding where document is to be filed
- Underline name or subject of how it is to be filed
- Every paper in patient's chart should have a name and date

Sorting Files
Arranging papers in a filing sequence
- Alphabetical
- Numeric
- Days of the week
- Days in the month
- Months of the year

Storing and Filing Files
- Inserted face up
- Most recent date on top
- Document completely in file

Locating Misplaced Files
Missing Document Only
- In the folder in front of or behind the correct folder
- Between folders
- Under the files
- Patient with a similar name

Entire medical record
- Physician's desk
- Billing department
- Nursing station
- Office manager

12 Rules of Indexing
1. Last names are considered first, then first name second.
2. Nothing comes before something
- Smith, T.
- Smith, Thomas
3. Hyphenated names are considered one unit
4. The apostrophe is disregarded
5. When a determination of order cannot be made, index in the order the name is written.
- Chang Liu
6. Names with prefixes are considered part of the name
- Von Hagen
7. Abbreviated names are filed as written
8. Mac and Mc are filed in alphabetical order
9. Married women are indexed by their legal name
10. Titles are not used as filing units
11. Terms of seniority, profession or academic degree are only used to distinguish same names
12. Articles (The and A) are disregarded when indexing

Common appointment book abbreviations
CPE/CPF: complete physical exam
NP/New Pat: new patient
NS: no show
Px: physical
OV: office visit
FU: follow up
ReC: recheck
Ref: referral
Can: cancelled
N&V: nausea & vomitting
Pgt: pregnancy test
RS: reschedule

Common time slots for appointments
Physical: 1 hour
School Physical: 30 minutes
Recheck: 15 minutes
Dressing Change: 10 minutes
BP Check: 5 minutes
Patient Teaching: 30 minutes-1 hour

CC (Chief Complaint)
- Nature and duration of pain, if any
- When symptoms were first noticed by patient
- Patient's opinion of causes of problem
- Remedies patient may have applied
- Patient has had same/similar condition in the past
- Other treatment received for condition in the past

CHEDDAR
C- Chief Complaint
H- History
E- Examination
D- Details (of problem and complaint)
D- Drugs & dosages
A- Assessment
R- Return visit information, if applicable