Important Things A CMAA Should Know 2

Rules that must be followed under physician-patient relationship
1.Patient is expected to compensate the physician for all services provided
2. The patient is expected to adhere to any directions/guidance provided by the physician
3. If the physician terminates the contract, the pt must be provided with advance notice of these intentions as well as given enough time to seek the services of another physician.

Scheduling New Patients
1. Obtain and verify general information
2. Gather appropriate information regarding a patient referral (if applicable)
3. Determine patient's cc (chief complaint).
4. Make patient aware of various dates & times available to be seen.
5. Enter appropriate time for appointment.
6. Determine financial arrangements (insurance, cash, etc.).
7. Provide directions as needed.
8. Verify information and appointment time/date.

Scheduling Conflicts
1.Late patients: Advise to arrive 30 minutes prior to appointment time.
2.Emergency Calls: Arrangements made to be seen same day if available
3.Cancelled Appointments: Remove original time, schedule new appointment.
4.Unscheduled Patients: Accommodate as best as possible, ensure patient that making appointment is the best way to ensure care.
5.Failed appointments: Notate in patient's chart and appointment book, and attempt to reschedule.
6.Delayed patient wait time: Explain reason (without giving too much detail) and provide patient with the option to reschedule if desired by the patient.

Types of Mail
1. Express Mail: available 365 days per year, for items up to 70lbs in weight, and up to 108" in height.
2. First Class Mail: letters, postal cards, postcards, and business reply mail
3. Priority Mail: First Class mail weighing more than 13oz.
4. Certified Mail: proof of delivery
5. Bulk Mailing: mailing large volumes of information which is presorted by zipcode.

Health Insurance: Verification of Insurance Benefits
1. Identify type of insurance or managed care plan.
2. Make copies of card; front and back.
3. Call carrier to verify services and benefits.
4. Record this information in medical record and VOB (verification of benefits) form.
5. Provide patient with form listing requirements and restrictions of plan, and have them read and sign the form.
6. Collect deductible/co-payment if applicable.

Types of Health Insurance
1. Individual Policies: Usually ineligible to receive government paln; high premiums and limited benefits.
2. Group Policies: Provides coverage for employees under a single contract. This type of coverage is characterized by greater benefits, and low premiums.
3. Government Plans: Available to large groups of people who meet specific eligibility criteria. TRICARE, Medicare, Medicaid, and Worker's Compensation are examples.

Insurance Terms
1. Assignment of Benefits: An arrangement by which a patient requests that their health benefit payments be made directly to the physician.
2. Benefit: The amount payable by the carrier toward the cost of services for which the patient is eligible for.
3. Deductible: The amount an individual must pay for health care expenses before insurance covers the cost.
4. Co-payment: The portion of a service fee that the patient must pay.
5. Policy: A document that describes the insurance coverage for an individual or property.
6. Premium: The amount the patient pays for an insurance contract.

Medical Records Management: Creating a Medical Record
1. Determine if new or established patient.
2. Obtain required general information.
3. Enter the information into patient history form.
4. Review the form for accuracy
5. Enter patient's name into computerized ledger
6. Assemble forms, prepare folder, and file.

Components of the Medical Record
1. Personal and Medical History: Past illnesses, surgical operations, patient's daily health habits.
2. Patient's Family History: Health/diseases of family members and a record of causes of death.
3. Patient's Social History: Included information regarding the patient's lifestyle: e.g., tobacco use, alcohol use, drug use.
4. Patient's CC (Chief Complaint): A statement of the patient's symptoms.
5. Diagnosis: A decision made based on the information regarding the patient's history and the results of the doctor's examination.

SOAP approach to documenting
A format for progress notes based on the letters of the word SOAP.

S: Subjective Impressions: given by patient
O: Objective Clinical Evidence: test results, observed
A: Assessment/Diagnosis: probably diagnosis
P: Plans for further studies, treatment, or management: treatment

Filing: Indexing Rules
1. last name, first name, middle/initial.
2. Hyphenated portion of name is one unit. Ex: Anna Smith-Meyer = Smithmeyer, Anna.
3. Apostrophes are NOT used in filing.
4. Titles and terms of seniority are only used to distinguish from an identical name.
5. When indexing a company, articles such as "the" and "a" are not used. Ex: The Mandarin Office = Mandarin Office

Positional and Directional Terms
1. Anterior (ventral): Front surface of the body.
2. Posterior (dorsal): Back side of the body
3. Deep: Away from the surface
4. Proximal: Near the point of attachment to the the trunk or near the beginning of a structure.
5. Distal: Far from the point of attachment to the trunk or far from the beginning of a structure.
6. Inferior: Below another structure
7. Superior: Above another structure
8. Medial: Middle or near medial plane of the body
9. Lateral: Pertaining to the side
10. Supine: Lying on the back
11. Prone: Lying on the abdomen.

Cranial Bones
1. Frontal Bone: forms the anterior part of skull and forehead.
2. Parietal bones: forms the sides of the cranium.
3. Occipital Bone: forms the back of the skull. Large hole @ ventral surface (foramen magnum) which allows the brain communication with the spinal cord.
4. Temporal Bone: forms the two lower sides of the cranium.
5. Ethmoid Bone: forms the roof of the nasal cavity.
6. Sphenoid Bone: anterior to the temporal bones.

Facial Bones
1. Zygoma: cheekbone.
2. Lacrimal Bones: paired bones at the corner of the eyes that cradle tear ducts.
3. Maxilla: upper jaw bone.
4. Mandible: lower jaw bone.
5. Vomer: bone that forms the posterior/inferior part of nasal septal wall between nostrils.
6. Palatine Bones: make up part of the roof of the mouth.
7. Inferior Nasal Conchae: make up part of the interior of the nose.

Upper Extremities
1. Humerus: Upper arm bone
2. Ulna: Lower medial arm bone
3. Radius: Lateral lower arm bone (in line w/ thumb)
4. Carpals: Wrist bones. 2 rows of 4 bones in each wrist.
5. Metacarpals: Five radiating bones in the fingers; the bones the in the palm.
6. Phalanges: Finger bones. Each finger has 3 phalanges except the thumb. 3 phalanges: proximal, middle, distal phalanx. Thumb has a proximal and a distal phalanx.

Lower Extremities
1. Femur: thighbone
2. Patella: knee cap
3. Tibia: Shin
4. Fibula: Smaller, lateral leg bone
5. Malleolus: ankle
6. Tarsal: hind foot bone
7. Metatarsal: midfoot bone
8. Phalanx: toe bones, 14 total (2 in large toe, 3 in each other toes)

Muscle Actions
1. Extension: to increase the angle of the joint
2. Flexion: to decrease the angle of a joint
3. Abduction: movement away from the midline
4. Adduction: movement towards the midline
5. Supination: turning the palm or foot upward
6. Pronation: turning the palm or foot downward
7. Dorisflexion: raising the foot, pulling toes toward the shin
8. Plantar flexion: lowering the foot, pointing tows away from shin
9. Eversion: turning outward
10. Inversion: turning inward
11. Protraction: moving a part of the body forward
12. Retraction: moving a part of the body backward
13. Rotation: revolving a bone around its axis.

Types of Fractures
1. Comminuted: the bone is crushed and/or shattered.
2. Compression: the fractured area of the bone collapses on itself.
3. Colles: the break of the distal end of the radius at the epiphysis often occurs when the patient has attempted to break his/her fall.
4. Complicated: the bone is broken and pierces an internal organ.
5. Impacted: the bone is broken and the ends are driven into each other.
6. Hairline: a minor fracture appears as a thin line on an x-ray and may not extend completely through the bone.
7. Greenstick: the bone is partially bent and partially broken; common in children because the bones are still soft.
8. Pathologic: any fracture occurring spontaneously as a result of disease.
9. Salter-Harris: a fracture of the epiphyseal plate in children.
10. Sprain: traumatic injury to a joint involving the soft tissue. Includes muscles, tendons, and ligaments. Usually as a result of overuse or overstretching.

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