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
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