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Table of Contents
Pg Numbers
week1 ……………………………………………………………………………………………….4-9
Section 1-
1. What is HIPAA?
2. HIPAA Terms: What does the following mean, Describe Briefly.
● DII
● Disclosure
● Health Care Operation
3. What is the following meaning of each abbreviation explain briefly?
● IIHI
● PHI
● PII
4. Explain what is the security standard.
5. What does treatment refer to?
6. Explain the term workforce?
7. Individual Patient Rights. Patient Always has the right to request a list (5) pointers.
8. Components of the Medical Record. There are 15 pointers of protected information in the
Medical Record list them
9. Safeguard for PHI: List the Pointers in each.
10. Disclosure of Protected Health Information. Explain what I can say, and what can’t I say.
11. Draw and label the pulse points
12. Draw or print the heart
13. Medical Terminology
Section 2
Week 2- ………………………………………………………………………………………..10-16
Section 1
1. What do you need to process a request for payment?
2. What information will be required for new patients?
3. What information will be required for existing patients?.
4. Common prescription abbreviations
5. Types of Needles
Section 2-
1. Using the ICD Index- List 3 basic steps for using the disease index.
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2. What are the OSHA Standards and Precautions?
3. Disposable Procedures- Proper Disposable Of contamination articles is an important component
of OSHA rules. In a chart form, List the basic container, the regular waste container, and the
sharp container.
4. Vital Sign Basic- Temperature Basic
5. Pulse Basic
6. Respiration Basic
7. Blood Pressure Basic
8. General Clinical Office Tips- List Things to do before the office opens.
9. List things to do before the office closes.
10. List at least 5 types of communication and briefly explain
Week 3-..................................................................................................................................17-20
1. Legal and Ethical Aspects of Medicine- Confidentiality
2. Legal and Ethical Aspects of Medicine- Consent
3. Introduction to Pharmacology for Fundamentals
Week 4- ……………………………………………………………………………………21-24
1. What is Medical Office Administration?
2. What Are Medical Administration Duties?
3. Medical Administrative Assistant Main Job Responsibilities
4. Administrative Assistant Skills
5. Administrative Procedures
6. The Importance of Administrative Procedures
References……………………………………………………………………………………..25
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Assignment- Week 1
1. What is HIPAA?
Federal law required the creation of national standards to protect sensitive patient health
information from being disclosed without the patient's consent or knowledge.
2. HIPAA Terms: What does the following mean, Describe Briefly?
1. De-Identified Information (DII) -The de-identification process removes all direct identifiers
from patient data and allows organizations to share it without the potential of violating
HIPAA.
2. Disclosure- Disclosure is defined by HIPAA as the "release, transfer, provision of access
to, or divulging in any manner of information outside the entity holding the information.
3. Health Care Operation- Refers to using protected health information (PHI) to support the
business activities of the practice. This may include employee training, marketing, fund-
raising, licensing, and quality assessments
3. What is the following meaning of each abbreviation explain briefly?
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a. IIHI (Individually Identifiable Health Information) -A subset of health information that
identifies the individual or can reasonably be used to identify the individual; HIPAA protects
individually identifiable health information
b. PII (Patient Identifiable Information)-Individually identifiable health information, is
information, including demographic data, that relates to the individual's past, present, or future
physical or mental health or condition, the provision of health care to the individual, or.
c. PHI-The HIPAA Privacy Rule provides federal protections for personal health information
held by covered entities and gives patients an array of rights with respect to that information.
4. Explain what is the security standard.
The HIPAA Security Rule establishes national standards to protect individuals' electronic
personal health information that is created, received, used, or maintained by a covered entity.
Security Standard Protects the Confidentiality, Integrity, and Availability of PHI
■ Confidentiality is the prevention of unauthorized disclosure of data.
■ Integrity is the prevention of unauthorized modification of data.
■ Availability is the prevention of loss of access to resources and data.
5. What does treatment refer to?
Treatment refers to the action or way of treating a patient or a condition medically or surgically.
6. Explain the term workforce.
Workforce refers to employees, volunteers, trainees, and other people under the direct control of
a covered entity.
7. Individual Patient Rights. Patient Always has the right to request list (5) pointers.
Patients Always Have the Right to Request
1. Access to information.
2. Amendment of PHI.
3. Additional restriction of information.
4. Alternative communications.
5. Accounting of disclosures.
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8. Components of the Medical Record. There are 15 pointers of protected information in the
Medical Record list them
Protected Information in the Medical Record
1. Patient registration form
2. Insurance information
3. Consent forms
4. HIPAA forms
5. Health history form
6. Physical examination
7. Progress notes
8. Laboratory reports
9. Diagnostic reports (x-ray, MRI, ECG, etc.)
10. Medication record
11. PT, OT reports
12. Homecare reports
13. Hospital documents (OP, D/C, pathology reports)
14. Correspondence
15. Consultation reports
9. Safeguard for PHI: List the Pointers in each.
Administrative.-
● Verify the identity of the person picking up health records.
● Verify the identity of the person on the telephone.
● Report suspected breach of confidentiality.
● Ask all patients to read and sign notices of privacy practices (NPP).
Technical -
● Require a unique password and user name for each staff member accessing medical
records.
● Use and regularly update firewall protection to prevent “hacking.”
● Delete user names and passwords of employees who leave the practice.
● Utilize tracking software to monitor employees’ activities in the system.
● Require that staff members log off when away from the computer.
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Physical -
❖ Store patient files away from patient-accessible areas.
❖ Lock file cabinets.
❖ File medical records before cleaning staff come in at the end of each day.
❖ Do not post provider schedules with patients’ names in areas where other patients can
see them.
❖ Sign-in sheets in the waiting room are okay; instruct patients to use first name and last
initial only.
10. Disclosure of Protected Health Information. Explain what I can say, and what can’t I say.
Disclose Don’t Disclose
❖ Location of the patient and general
condition:
❖ Specific conditions:
❖ • “She is in room 133, in stable
condition.”
❖ “He is in ICU, in critical condition.
❖ “Her fractured leg has been cast and
she has been sedated.”
❖ “Inoperable tumors were found during
his surgery.”
❖ PHI for treatment, payment, and
operations (TPO)
❖ PHI for other than TPO
❖ treatment, payment, and health care
operations
❖ “PHI is never given out without
authorization; if you obtain signed
authorization from the patient, I can
release the requested information.”
❖ Any DII ❖ DII can be disclosed without consent
because personal identifiers are
omitted in the data (used for research,
public health, etc.).
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11. Draw and label the pulse points
12. Draw or print the heart
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Week 2:Section 1
1. What do you need to process a request for payment?
➢ Patient’s legal name
➢ Relationship to insured (self, spouse, child, other)
➢ Address and telephone number
➢ Individual identification number and Social Security number
➢ Group identification number
➢ Employer of insured party
➢ Claims address, department, proper P.O. Box
➢ Date of service
➢ Diagnostic codes (that support treatment)
➢ Treatment codes
2. What information will be required for new patients?
● Photocopy of insurance card (placed in patient’s file or added to electronic
health record)
● Verification of eligibility (call, fax, or Internet verification)
● Photocopy of driver’s license or other photo identification (placed in
patient’s file)
3. What information will be required for existing patients?
❖ Has your insurance changed?
❖ Has your name, address, phone number, or e-mail address changed?
❖ Has your employment changed?
4. Common Prescription Abbrevation
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Section Two
1. Using the ICD index- list three basic steps for using the disease index.
➔ Locate the main term in the Index to Diseases (Volume 2).
➔ If the phrase “see condition” is found after the main term, a descriptive term (an
adjective) or the anatomic site has been referenced instead of the disorder or the
disease (the condition) documented in the diagnostic statement.
➔ When the condition listed is not found, locate main terms such as syndrome,
disease, disorder, derangement of, or abnormal.
2. What is OSHA standard and precaution?
➢ The Occupational Safety and Health Administration (OSHA) has mandated
various standards to ensure the safety of all healthcare professionals and their
patients, including disposal procedures and cleaning up spills of biohazardous
material.
3. Disposable Procedures- proper disposal of contamination articles is an important
component of OSHA rules. In chart form, list the biohazards container, the regular waste
container, and the sharp container.
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Biohazard Container Regular Waste Container Sharp Container
All supplies contaminated
with blood or body fluids,
such as:
➢ Gloves
➢ Gauze
➢ Bandages
➢ Gowns
➢ Other contaminated
linens
➢ Wrappers
➢ Paper towels
➢ Examination table
paper
➢ Supplies not
contaminated with
blood or body fluids
➢ Needles
➢ Capillary tubes
➢ Dermal puncture
lancets
➢ Broken glass or slides
4. Vital sign basic- Temperature basic
Temperature Basics:
1. Temperature increases with infection, exercise, crying, and pregnancy.
2. Temperature is decreased in the morning.
3. For rectal temperature, subtract 1 degree.
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4. For axillary temperature, add 1 degree.
5. Note methods of temperature assessment, such as oral, rectal, axillary, or aural
5. Pulse Basic:
1. Pulse increases with physical activity, pain, anxiety, fever, pregnancy, and certain
medications.
2. Pulse is decreased in the elderly and with certain medications.
3. Note pulse rhythm and volume.
6. Respiration Basics:
1. Respiration increases with physical activity, anxiety, certain medications, and
fever.
2. Respiration is decreased in elderly and with certain medications.
3. Note respiratory rhythm and depth.
4. Note abnormal breath sounds, if any.
5. Take respiration rate without the patient knowing.
7. Blood Pressure Basics:
1. BP increases with physical activity, anxiety, stress, smoking, and certain medications.
2. BP decreases with certain medications.
3. Make sure cuff is correct size for patient.
4. Never hold bell with the thumb.
5. Position cuff so scale is easily visible.
6. Position the patient’s arm at heart level and support the arm.
7. Wait for 1 to 2 minutes before repeating BP.
8. Note arm (L or R) and patient position (sitting or lying)
8. General Clinical Office tips- list things to do before the office opens:
Things to do before the office opens:
1. Clean all examination rooms.
2. Makeup bleach solution.
3. Perform quality control on various laboratory equipment.
4. Record QC results.
5. Record temperatures of refrigerators, freezers, and so forth.
6. Make sure all instruments are in working order, such as otoscopes, lights, etc.
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9. Things to do before the office closes:
1. Pull charts for the following day.
2. Pick up examination rooms and empty trash in all areas.
3. Wipe down counters, scales, and so forth with bleach solution.
4. Sterilize instruments as needed
10. List at least 5 types of communication and briefly explain
The Types of Communication
1. Verbal Communication Verbal communication is about language,
both written and spoken. In general, verbal
communication refers to our use of words
while nonverbal communication refers to
communication that occurs through means
other than words, such as body language,
gestures, and silence.
2. Nonverbal Communication Is the transfer of information through body
language, facial expressions, gestures,
created space, and more. For example,
smiling when you meet someone conveys
friendliness, acceptance, and openness.
3. Written Communication A 'Written Communication' means the
sending of messages, orders, or
instructions in writing through letters,
circulars, manuals, reports, telegrams,
office memos, bulletins, etc. It is a formal
method of communication and is less
flexible.
4. Intrapersonal Communication Can be defined as communication with
one’s self, and that may include self-talk,
acts of imagination and visualization, and
even recall and memory
5. Oral Communication Oral communication implies
communication through mouth.
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It includes individuals conversing with
each other, be it direct conversation or
telephonic conversation. Speeches,
presentations, and discussions are all
forms of oral communication.
6. Mass Communication Is the process of imparting and exchanging
information through mass media to large
segments of the population. Mass
communication involves sending a single
message to a group. It allows us to
communicate our message to a large
number of people.
7. Listening To listen is to give attention to sound or
action. When listening, one is hearing
what others are saying, and trying to
understand what it means. The act of
listening involves complex affective,
cognitive, and behavioral processes
8. Eye Contact Eye contact occurs when two people look
at each other's eyes at the same time. In
humans, eye contact is a form of
nonverbal communication and can have a
large influence on social behavior. Eye
contact shows that you are engaged.
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Week 3-
Legal and Ethical Aspects of Medicine- Confidentiality
Confidentiality is a key component of the patient-physician relationship. Patients who believe
that their health information will remain confidential are more likely to provide doctors with
more accurate information, which in turn will lead to better medical advice.
Here are 3 things you cannot forget about confidentiality:
1. Most breaches are inadvertent
You may encounter a particularly challenging case that you want to share with your colleagues.
That is okay, as long as you don’t disclose information that can reasonably lead to the identity of
the patient - like name, initials, prominent family members, or occupation (if unusual). You
should also refrain from sharing cases on social media, especially those that might be on the
news, as you can easily lose control of who sees this information once posted.
2. Confidentiality applies to individuals, not families
It is not uncommon for physicians to care for multiple family members. This can be very
rewarding but also fraught with ethical dilemmas. What if your patient asked you why you
prescribed birth control pills to her 15-year-old daughter? Or what if you received a request from
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an insurance company for your patient’s family history after you recently diagnosed his father
with coronary artery disease?With few exceptions, you can only disclose medical information
with your patient’s implied or express consent and the information disclosed should have been
collected directly from that patient.
3. There are exceptions to confidentiality
The law recognizes specific situations where you need to disclose information for the greater
public good. An example of mandatory reporting is when you suspect that a child is in need of
protection. There are also situations where it is permissible for a physician to report to
governmental agency – for instance in the situation in which a patient demonstrates to you that
he or she will likely inflict serious harm on a specific person or group of persons.
Legal and Ethical Aspects of Medicine- Consent
Here are 3 things that you should not miss when obtaining valid consent:
1. Assess the patient’s capacity
Before you even obtain consent, you need to be satisfied that the person can understand the
nature of the proposed treatment, its anticipated effects, and the consequences of refusal.
In most provinces, capacity does not depend on age but varies according to the person and the
complexity of the decision. A 10-year-old may appreciate that his broken foot needs a cast but
that same person may not understand the operation proposed to fix it.
2. Inform the patient of any special risks
During the consent process, you will need to provide your patients with information about the
expected benefits, possible material risks, any alternative course of actions, and the likely
consequences of not having the treatment. You should also discuss any special risks that might
apply to the particular patient. Developing an abnormal sense of touch after carpel tunnel surgery
may affect a dentist differently than a retired librarian.
3. Be sure that the person is giving consent voluntarily
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When getting consent, take care to ensure that this person is choosing freely and is not being
coerced by anyone, including you. Patients should be given an appropriate time to deliberate and
the information should be presented factually. While in some cases it may be important for the
patient’s friends or family to provide input, remember that you are only treating the patient.
Patients have the right to choose, doctors have the duty to inform.
Introduction to Pharmacology for Fundamentals
Pharmacology is one of the most important branches in pharmacy, it deals with the study of the
drug, drug's effect on the body and body responsible for the drug which has been taken is called
pharmacology. Pharmacology has two main branches-
(1) Pharmacodynamic
(2) Pharmacokinetic.
The study of drugs or chemicals and the effects they have on living animals is called
pharmacology. Pharmacology explains what drugs are, what they do to body functions and what
the body does to them. Pharmacology also explains why a person may experience side effects
when they take drugs and why there is such a wide spectrum of differences between drug actions
in different people.
Once the drug is bound to a protein it exerts a therapeutic effect on the body, this is the
pharmacodynamics of a drug. There is an enormous list of different drugs and their actions in the
body.
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Pharmacokinetics is the study of what happens to drugs once they enter the body. The main
stages include:
(1) The absorption of the drug into the blood and across cell membranes to enter the cells;
(2) The distribution of the drug throughout the body
(3) The metabolism or breakdown of the drug; and
(4) The excretion of the drug from the body
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Week 4-
Administrative Medical Office Procedures and Practices
What is Medical Office Administration?
Medical office administration encompasses all of the managerial and support roles that provide
administrative services in a medical office setting, including records and billing clerks,
receptionists, office managers, and administrative assistants.
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What Are Medical Administration Duties?
● Scheduling and managing patient appointments.
● Answering the phone and taking patient questions.
● Filing, updating, and organizing patient records.
● Planning and coordinating hospital transfers and laboratory tests and services.
● Processing forms for insurance claims.
Administrative Assistants provide general office support for a variety of administrative tasks that
may include answering incoming calls, making travel and meeting arrangements, preparing
reports, maintaining filing systems, managing supplies, and making sure company operations run
smoothly.
Examples of relevant job titles:
- Administrative Assistant
- Office Assistant
- Receptionist
- Office Manager
Administrative Assistance should have:
★ Communication skills: You should act confidently when it comes to exchanging
information with employees of various seniority levels.
★ Organizational skills: You should be able to organize papers and data, as well as analyze
information and projects the way they can be presented as achievable goals.
★ Time management skills: You should know how to manage the time devoted for each
task, as well as how to prioritize projects
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Administrative Procedures:
Administrative procedures are a set or system of rules that govern the procedures for managing
an organization. These procedures are meant to establish efficiency, consistency, responsibility,
and accountability.
The Importance of Administrative Procedures:
Administrative procedures are important because they provide an objective set of rules by which
an organization is governed. They also help establish the legitimacy of management action by
ensuring the application of management rules and decisions is done in an objective, fair, and
consistent manner. Finally, they help ensure that managers are held accountable for decisions
that deviate from the procedures.
References
