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Ma Notes
1. Contacts • Phone/E-Mail
Name
Ph: e-mail:
Name
Ph: e-mail:
Name
Ph: e-mail:
Name
Ph: e-mail:
Name
Ph: e-mail:
Name
Ph: e-mail:
Name
Ph: e-mail:
Name
Ph: e-mail:
Name
Ph: e-mail:
Name
Ph: e-mail:
Name
Ph: e-mail:
Name
Ph: e-mail:
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2. MA
Notes
MA
Notes
Medical Assistant’s Pocket Guide
Cindi Brassington, MS, CMA (AAMA)
Cheri Goretti, MA, MT (ASCP),
CMA (AAMA)
Purchase additional copies of this book at
your health science bookstore or directly
from F.A. Davis by shopping online at www.
fadavis.com or by calling 800-323-3555(US)
or 800-665-1148 (CAN)
FA Davis’s Notes Book
3rd Edition
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5. Look for our other Davis’s Notes titles
available now!
Coding Notes: Medical Insurance Pocket Guide
ISBN-978-0-8036-2359-0
MA Review NotesPlus: Exam Certification Pocket Guide
ISBN-978-0-8036-4034-4
For a complete list of Davis’s Notes and
other titles for health care providers,
visit www.fadavis.com.
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6. 1
ADMIN
HIPAA
The Health Insurance Portability and Accountability Act (HIPAA)
of 1996 mandates privacy for health information, standards for
electronic transactions of health information and claims, security
of electronic health information, and national identifiers for the
parties in health care transactions.
Glossary of HIPAA Terms
The following terms appear in HIPAA guidelines and are used in
determining when and how to store and release health
information.
Business Associate
A person who, on behalf of the covered entity, performs or
assists in the performance of a function or activity involving
the use of individually identifiable health information (IIHI). (Does
not include members of the covered entity’s workforce.) Exam-
ples include legal, actuarial, accounting, consulting, and auditing
firms.
De-Identified Information (DII)
Health information that has had all personal identifiers removed
from the data set. May be disclosed without consent of the
individual.
Disclosure
Releasing, transferring, providing access to, or divulging in any
manner information outside the entity holding the information.
Health Care Operations
Refers to using protected health information (PHI) to support
business activities of a practice. This may include employee
training, marketing, fund-raising, licensing, and quality
assessments.
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7. 2
ADMIN
Individually Identifiable Health
Information (IIHI)
Created by a health care organization, relates to past, present, or
future condition of an individual, and could be used to identify
that individual.
Patient Identifiable Information (PII)
Identifiers within health information that could be used to iden-
tify an individual.
Payment
Refers to using PHI to obtain payment of health care services.
This may include the operations a health insurance plan under-
takes before paying for services.
Privacy Standard
Having policies and procedures in place to control who has
access to protected health information (PHI).
Protected Health Information (PHI)
Any patient identifiable information regardless of the media form
it is in, whether at rest or in transit.
Security Standard
Protect 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.
Treatment
Refers to using PHI to provide, coordinate, or manage health care
and related services.
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8. 3
ADMIN
Use
Refers to sharing, employing, applying, utilizing, examining, or
analyzing individually identifiable health information by employ-
ees or other members of an organization’s workforce.
Workforce
Employees, volunteers, trainees, and other people under the
direct control of a covered entity.
Individual Patient Rights
Patients Always Have the Right to Request
■ Access to information.
■ Amendment of PHI.
■ Additional restriction of information.
■ Alternative communications.
■ Accounting of disclosures.
Components of the Medical Record
Protected Information in the Medical Record
■ Patient registration form
■ Insurance information
■ Consent forms
■ HIPAA forms
■ Health history form
■ Physical examination
■ Progress notes
■ Laboratory reports
■ Diagnostic reports (x-ray, MRI, ECG, etc.)
■ Medication record
■ PT, OT reports
■ Homecare reports
■ Hospital documents (OP, D/C, pathology reports)
■ Correspondence
■ Consultation reports
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9. 4
ADMIN
Safeguards for PHI
Administrative
■ Verify identity of person picking up health records.
■ Verify identity of person on telephone.
■ Report suspected breach in confidentiality.
■ Ask all patients to read and sign notice 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
computer.
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.
■ Sign-in sheets in the waiting room are okay; instruct patients
to use first name and last initial only.
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10. 5
ADMIN
Disclosure of Protected Health Information
What Can I Say, What Can’t I Say?
If a friend or family member asks for information regarding a
specific patient—BY NAME, you may:
Disclose Don’t Disclose
Location of the patient and
general condition:
Specific conditions:
• “She is in room 1133, in
stable condition.”
• “He is in ICU, in critical
condition.”
• “Her fractured leg has been
casted 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. 6
ADMIN
Authorization to Release Health
Care Information
Patient______________________________________________________
Date__________________________________________________________
Patient ID#___________________________________________________
I request and authorize ______________________________ office to
release the health care information of ______________________
(patient name) to (name and address of destination of the
medical information):
_______________________________________________________________
_______________________________________________________________
This request and authorization applies to (sign appropriate lines):
1. All health care information EXCLUDING specific information
relating to sexually transmitted diseases, HIV/AIDS diagnosis
and treatment, alcohol and/or drug history, and any care
related to psychiatric disorders and mental health.
___________________________________________________________
2. All health care information INCLUDING specific information
relating to sexually transmitted diseases, HIV/AIDS diagnosis
and treatment, alcohol and/or drug history, and any care
related to psychiatric disorders and mental health.
___________________________________________________________
I understand that my expressed consent is required for release
of information relating to diagnosis and treatment of sexually
transmitted diseases, HIV/AIDS, drug and alcohol abuse, and
psychiatric disorders and mental health care. If I have been
tested, diagnosed, or treated for the aforementioned, permission
by my signature at the item authorizes you to release information
regarding that testing, diagnosis, and/or treatment.
_______________________________________________________________
Signature of patient or authorized representative
________________________ ___________________________
Relationship to patient Date
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12. 7
ADMIN
Disclosures for Public Interest
The following disclosures are permitted without the individual’s
authorization because these items have an impact on public
health and/or safety.
Court Orders
Can be obtained without patient’s consent if ordered by a judge.
Communicable Diseases and Work-Related
Illnesses and Accidents
Disclosure to public health authorities is used to prevent acci-
dents and illness and monitor trends.
Reporting Victims of Abuse, Neglect, or
Domestic Violence
Health care providers are legally responsible for reporting cases
to social services and law enforcement.
Law Enforcement Purposes
■ To identify missing persons or a suspect
■ To alert police of death of a suspect
■ When PHI is evidence of crime or can be used as such
■ When there is perceived serious threat to patient
Deceased Persons
PHI may be disclosed for the purpose of organ and tissue trans-
plant/donation.
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13. 8
ADMIN
Privacy Policy Documents
Notice of Privacy Practices
Describes the use of PHI for carrying out treatment, payment, or
health care operations. A written acknowledgement is recom-
mended rather than verbal.
Consent for Use or Disclosure for TPO
Patient consent to the use of and disclosure of health information
for treatment, payment, or health care operations (TPO)
(optional).
Authorization
Authorization to use or disclose PHI must be obtained when a
consent form does not apply or another exception otherwise
permitting use or disclosure of PHI does not apply. See page 6.
Business Associate Contract (BAC)
Describes protection of privacy of a patient’s PHI when using
outside entities that provide services for your organization where
access to PHI is necessary.
Data Use Agreement
An agreement with a recipient of the PHI data that limits his or
her use of PHI.
Privacy Officer Job Description
A written description of the Privacy Officer’s roles and
responsibilities.
Termination Procedure
A written policy of termination of employees who fail to comply
with internal privacy policies and procedures.
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16. 11
ADMIN
Seven Components of a Compliance Plan per
Recommendations of the Office of Inspector
General (OIG)
■ Conduct periodic internal monitoring and audits.
■ Implement compliance and practice standards.
■ Designate a HIPAA compliance officer.
■ Conduct training and education.
■ Respond appropriately to detected offenses and develop a
corrective action plan.
■ Develop open lines of communication to staff for asking
questions and refer to the policies and procedures manual.
■ Enforce disciplinary standards through well-publicized
guidelines that are explained in detail in the policies and
procedures manual.
Web Resources for HIPAA
Health Insurance Portability and Accountability Act of 1996: Title
1 Statutory Text
http://www.cms.gov/Regulations-and-Guidance/HIPAA-
Administrative-Simplification/HIPAAGenInfo/index.html
HIPAA Academy
http://www.HIPAAacademy.net
American Medical Association—HIPAA: Health Insurance Porta-
bility and Accountability Act
http://www.ama-assn.org/go/hipaa
U.S. Department of Health & Human Services–Health Informa-
tion Privacy
http://www.hhs.gov/ocr/privacy/
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18. 13
ADMIN
Electronic Health Records
Electronic health records (EHR) features:
1. Patients’ personal and medical data (input by MA or
physician).
2. Insurance billing through paperless Internet-encrypted
connections to third-party payors.
3. Prescription information periodically updated to ensure that
physicians prescribe correct dosages and do not prescribe in
conjunction with contraindicated medications.
4. Diagnosis and procedure codes periodically updated to
currently accepted codes.
5. Physician chart notes easily accessible when needed as
supporting documentation.
6. X-rays, CT scans, and MRIs digitally stored and retrieved at
multiple locations.
What Do I Need to Remember When Using
Electronic Health Records?
1. Be careful when inputting patient data. Errors in spelling or
errors in insurance ID#s will cause denial of payment.
2. Use encrypted connection when sending claims for
payment.
3. Send supporting documentation for payment as requested
in format requested by the insurer (PDF files, JPEG scans,
etc.).
4. All HIPAA guidelines for security and privacy apply to EHR
and paper documentation.
5. Notice of privacy practices (NPP) should be obtained from
patients with their signature and scanned into the EHR.
6. Back up EHR to encrypted Web storage or off-site storage as
directed by practice policy.
7. Never use office computers for unauthorized purposes since
viruses could corrupt the integrity and/or privacy.
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19. 14
ADMIN
Filing Systems
Medical records must be accessible for use. A consistent filing
system ensures proper access. Remember to keep medical
records confidential.
Alphabetical
Alphabetical filing systems order patient records by name.
UNIT 1 UNIT 2 UNIT 3 UNIT 4
LAST NAME FIRST NAME MIDDLE
NAME/INITIAL
TITLE(if
applicable)
Put Nothing Before Something
For example, Ann before Anne:
■ Jones, Ann
■ Jones, Anne
■ Jones, Anne M
■ Jones, Anne Marie (Anne before Anne M, before Anne
Marie)
■ Jones, Anne Marie II
Treat Hyphenated Names as One Name
For example:
■ JonesRodrigues, Ann
Alphabetize Titles
For example, Jr. before Sr.:
■ Kalinsky, Jerry Jr.
■ Kalinsky, Jerry Sr.
Blank before I (nothing before something), I before II:
■ Robert Muszinsky
■ Robert Muszinsky I
■ Robert Muszinsky II
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20. 15
ADMIN
Ignore Capitalization Within a Surname
File in ABC order:
■ MacDonald, Joe
■ McDonald, Joe
Married Versus Maiden Names
If Ms. Jones uses only the married name Rodrigues:
■ Rodrigues, Ann Jones
If Ms. Jones marries Mr. Rodrigues and hyphenates her name:
■ JonesRodrigues, Ann
Hyphenated Names
Use a cross-reference guide:
■ Jones, Ann see: JonesRodrigues, Ann
Two Patients With Same Name
Use address to file in order according to this chart:
UNIT 1 UNIT 2 UNIT 3 UNIT 4
CITY STATE STREET NAME STREET NUMBER
So, Mason before Washington:
Gary E. Burns
15 Mason Road
Willington, CT
Gary E. Burns
7 Washington Blvd
Willington, CT
And Willington before Windham:
Gary E. Burns
7 Washington Blvd
Willington, CT
Gary E. Burns
1 Adams Street
Windham, CT
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21. 16
ADMIN
Numeric
Consecutive Filing
File by increasing number. Think of counting in sequence:
573902 (or 57-39-02)
573903
573904
573905
Nonconsecutive Filing Systems
File by a primary unit other than the first digits in sequence.
Terminal Digit Filing
3 2 1
File the last two digits first 43 22 15
The second set is then used 43 23 15
Then the first units 44 23 15
43 22 16
42 21 17
NOTE: Terminal digit filing can be used to file patients by age.
The last two digits could correspond to the year of birth. Any one
of the sets of numbers could correspond to other variables, such
as the treating physician, the office site, month codes for appoint-
ment reminders, and so on.
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22. 17
ADMIN
Middle Digit Filing
2 1 3
File the middle two digits first 42 21 17
The first set is filed second 43 22 15
The last set is filed third 43 22 16
FILE NUMBER SIGNIFICANCE IN MY OFFICE:
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23. 18
ADMIN
Communication Skills
The Five Cs of Communication
Complete, Clear, Concise, Courteous,
and Cohesive
Sender
Encodes
message
Feedback
Receiver
Decodes message
Message
Speaking
Listening
Gesturing
Writing
Sender, Message, Receiver, and Feedback
Forms of Communication
Written Communications
Written communications sent via U.S. mail have an expectation
of privacy and can contain PHI for appropriate use. Written com-
munications can be used to relate information to:
■ Patients
■ Insurance providers
■ Attorneys
■ Law enforcement agencies
■ Social services
■ Other physicians or providers
■ Hospitals
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25. 20
ADMIN
Commonly Misspelled Words
Abscess Chancre Hemorrhoid Parietal
Aerobic Defibrillator Homeostasis Perineum
Aneurysm Desiccation Humerus Peritoneum
Asepsis Dissect Ischium Specimen
Asthma Epididymis Occlusion Surgeon
Benign Fissure Osseous Vaccine
Capillary Glaucoma Parenteral
Telephone Communications
Telephone privacy can be maintained in the office by closing a
door or reception screen. Always ask the identity of the caller
and give out information regarding a specific patient according
to HIPAA guidelines (see page 5). Also:
■ Greet the caller and identify yourself.
■ If you need to place the caller on hold, ask if you can do so:
“Can you hold please?”
■ When returning to the call, confirm the identity of the caller,
“Ms. Collins?”
■ When offering an appointment, offer specific times. For
example, “We can see you at 3 or 4:30 today.”
Scheduling New Patients
■ Be sure to get:
■ Patient’s telephone number
■ Patient’s date of birth
■ Type of insurance and insurance ID#
■ Reason for appointment
■ Name of referring physician (if applicable).
■ Offer directions to the office.
■ Ask the patient to bring photo ID for first visit.
■ Explain copayment policy. For example, “Copayment is due
at time of visit.”
■ Repeat the day and time of the appointment at the end of
the phone call.
■ Other items ________________________________________.
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26. 21
ADMIN
Scheduling Established Patients
■ Patient’s name
■ Reason for visit
■ Has insurance information changed since last visit?
■ Referral, if applicable
■ Other items ________________________________________
Time Required for Treatment
Write in the amount of time and room requirements for appoint-
ments as indicated below.
New Patient Examination _________minutes Room_________
Established Patient
Examination
_________minutes Room_________
Follow-up Visit _________minutes Room_________
Consultation _________minutes Room_________
Blood Testing _________minutes Room_________
X-rays _________minutes Room_________
ECG _________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
Continued
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27. 22
ADMIN
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
E-mail Communications
Do not expect privacy when using e-mail as a method of com-
munication. Not all e-mail recipients have exclusive access to
their e-mail account. Thus, you should never refer to PHI in an
e-mail.
Fax Communications
Faxing documents that contain PHI poses risks. If you must fax,
be sure to:
■ Recheck the fax number before hitting send.
■ Recheck authorization to release PHI.
■ Always use a cover sheet (see below).
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28. 23
ADMIN
Sample Fax Cover Sheet
ABC Medical Office
123 Main Street
Willington, CT 06279
TO: _____________
FAX #:
Page 1 of ___
Privacy Notice:
This fax transmission contains confidential information. This
information is solely for the intended recipient. Be aware that
disclosure, copying, distribution, or use of the contents of this
information is prohibited. If you have received this fax in error,
please notify us at ABC Medical Office at 860-555-9868 or by
e-mail at ABCMedical@email.net
What Form of Communication Should I Use?
Written Telephone E-mail
Appointment
reminders,
scheduling
Yes Yes* Yes
PHI Yes With the patient, not left
on answering machine
No
Schedule
changes
Yes, but may
not be practical
Yes* Yes
Requests for
payment
Yes Yes, at patient’s home,
not workplace
Yes
Insurance
questions
Yes Yes Yes
*Be careful when communicating about mental health, substance abuse, and
reproductive health appointments via telephone. It is recommended that
information regarding these appointments not be left on an answering machine
for people who do not live alone.
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29. 24
ADMIN
Banking
BEFORE YOU MAKE A BANK DEPOSIT
■ Does the number of checks in the deposit equal the number
of checks recorded?
■ Are all checks stamp-endorsed for deposit?
■ Check petty cash/change drawer and replenish change for
next day’s transactions.
■ Add checks and cash for total deposit.
■ Recheck math for accuracy.
■ Record amount of deposit.
■ Check the bank’s deposit amount to match recorded amount.
LIST CHECKS SINGLY OR ATTACH LIST
DOLLARS CENTS
CURRENCY
COINS
LIST EACH CHECK
CHECKS
AND
OTHER
ITEMS
ARE
RECEIVED
FOR
DEPOSIT
SUBJECT
TO
THE
PROVISIONS
OF
THE
UNIFORM
COMMERCIAL
CODE
OR
ANY
APPLICABLE
COLLECTION
AGREEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Total from
reverse side
TOTAL$
RE-ENTER
TOTAL HERE
PLEASE BE SURE ALL ITEMS ARE PROPERLY ENDORSED.
FIRST BANK
$
Bank Deposit Slip
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30. 25
ADMIN
General Administrative Office Tips
Opening the office each morning:
____1. Check answering machine or service for messages.
____2. Prioritize return phone calls.
____3. Log on to computer network.
____4. Print and post schedule.
____5. Check petty cash fund to ensure daily change, as needed.
____6. Check all rooms for cleanliness; prepare rooms if indicated.
____7. Inspect waiting room for cleanliness, hazards, and so on.
My password hint: __________________________________________
(NOTE: Write a hint that is not easily guessed by anyone else.
Do not write the password itself.)
Password expiration date: ___________________________________
During the day:
____1. File paper charts when able.
____2. Recheck authorization when disclosing PHI.
____3. Pick up waiting room and office space as needed.
____4. Stagger lunch and coffee breaks to ensure continuous
coverage of phones.
____5. Log off of the computer system when you go to lunch
or break.
____6. Write messages immediately to avoid forgetting
information.
____7. Have parcel packages and laboratory specimens ready
for pickup at courier-designated times.
Closing the office each day: _________________________________
____1. File patient medical records prior to arrival of cleaning staff.
____2. Prepare bank deposit and designate employee to go to
the bank.
____3. Balance the day sheet or computerized system fortheday.
____4. Log off of all computers and turn off the printer.
____5. Check the fax machine for paper in case of transmission
after hours.
____6. Turn off lights in treatment rooms, administrative area,
and reception area.
____7. Lock doors and set the alarm, per office policy.
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32. 27
MED INS
Billing
Billing for patient visits in a physician’s office or hospital setting
must be done without error to guarantee timely payment.
Proper coding of diagnoses to support treatment codes is also
vital to the financial health of a medical office.
What Do I 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
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)
Existing Patients
■ Has your insurance changed?
■ Has your name, address, phone number, or e-mail address
changed?
■ Has your employment changed?
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36. 31
MED INS
■ Item 1: Choose appropriate insurance carrier.
■ Item 1a: Insured I.D. number
■ Be sure to write number exactly as on patient’s insurance
card.
■ Item 2: Enter patient’s full name as it appears on insurance
card.
■ Doe, Jane, A
■ Okay to use commas or hyphen but no periods within
names.
■ If the patient is the insured, this item can be left blank.
■ Item 3: Patient’s date of birth
■ MM DD YYYY
■ Enter X to indicate gender.
■ Item 4: Insured’s name
■ Same convention as patient name.
■ Item 5: Patient address
■ Use no punctuation.
■ Example: 100 Elm Street apt 7
■ NUCC suggests leaving telephone blank.
■ If the patient’s address is the same as the insured, leave
blank.
■ Item 7: Insured address
■ If Item 4 is completed, this item should be completed.
■ Workers’ comp claims: use employer address.
■ Item 9: Enter name of secondary insured only if Item 11d is
marked yes.
■ Use conventions as in previous items.
■ Item 9d: Enter secondary insurance plan or program.
■ Item 10: Indicate if injury is due to employment, auto
accident.
■ Include postal code of state where accident occurred.
■ “Other accident” would indicate accident but neither WC
or auto.
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■ Item 10d: For workers’ comp claims: W2 for duplicate
claims, W3 for Level 1 appeal.
■ Item 11: Insurance policy group number for PRIMARY
insurance (right side of form).
■ Item 11b: Use if property and casualty claim # applies.
■ Item 12: Signature on file (patient’s) to release information
to insurance company for payment.
■ Item 13: Signature on file (patient’s) to authorize payment to
office and not patient.
■ Item 14: Date of current illness, injury, or pregnancy (LMP).
■ For services related to an illness, enter date first
symptoms occurred.
■ For injury related services, enter date of accident.
■ For chiropractic services, enter first date of treatment.
■ For pregnancy related services, add date of LMP.
■ Qualifier codes:
431 onset of current symptom or illness
484 last menstrual period
■ Item 17: Referring provider, use 2 character qualifiers:
DK ordering physician (only for DME claims)
DN referring provider
DQ supervising provider
■ Item 21: Diagnoses codes (use ICD-9-CM or ICD-10)
■ Use ICD-9-CM prior to Oct. 2015, ICD-10 after Oct. 2015.
■ Enter applicable ICD indicator to identify which version of
ICD codes is being reported.
• 9 ICD-9-CM
• 0 ICD-10-CM
■ Enter the indicator between the vertical, dotted lines in the
upper right-hand portion of the field.
■ Item 22: Resubmission codes
■ Use the following 4-digit codes for resubmission of
claims.
■ Used for previously paid claims, including zero paid
claims.
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■ Don’t use codes for denied claims.
1021 late charges received by facility business office
1023 primary carrier has made additional payment
1028 correcting procedure/service code
1029 correcting diagnosis code
1030 correcting charges
1031 correcting units, visits of studies
1034 correcting quantity dispensed
1035 correcting drug code
1037 services not covered by Medicare
1041 incorrect amount paid for original claim
1042 original claim has multiple incorrect items
1053 adjustment—miscellaneous
■ Item 24D: CPT/HCPCS codes for procedures (add modifier
when necessary).
■ Item 24E: Reference ICD-9-CM or ICD-10 code that supports
procedure (use ABCDEFGHIJKL).
■ Box 25: Federal Tax ID, doctor’s Social Security number, or
Employer ID number (needed to pay claim).
■ Box 33a: National Provider Identification (NPI) number
(check that number is correct).
CMS-1500 Checklist
■ Name on CMS-1500 appears exactly as name on insurance
card.
■ Insured identification number and group number are correct.
■ Patient/insured date of birth is rechecked and uses the
format MM DD YYYY.
■ Referring physician name and National Provider
Identification (NPI) are rechecked (if applicable).
■ Dates of service are correct and use the format MM DD YYYY.
■ Diagnostic and procedure codes are correct.
■ Check spelling.
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Glossary of Health Insurance Terms
The following terms and their definitions relate to health
insurance.
Birthday Rule: Rule that designates the parent with the earlier
birthday in the calendar year as the primary insurer for the
dependent children.
Clean Claim: Error-free insurance claim.
Copay, Copayment: Amount of money patient owes at each visit
(varies with insurers from $5 to $25).
Deductible: Amount of money paid out-of-pocket by the patient
at the beginning of each calendar year before health insurance
benefits begin to cover claims.
Explanation of Benefits (EOB): Document sent from the insur-
ance company to the patient outlining payment made to the
physician, write-offs, and any patient responsibility.
Health Maintenance Organization (HMO): Organization that
reimburses a health care provider for services delivered to a
covered patient in an individual, group, or public health plan,
according to an agreement between the provider and the HMO.
Preauthorization: Insurance company review and authorization
of a treatment plan and agreement to pay for such treatment.
Preferred Provider: Physician or other health care provider who
signs a contract with an insurance carrier to provide patient care
at a discounted rate.
Primary Care Provider: General practitioner designated by the
insurance plan as the first doctor the patient sees for most care.
(Specialist visits require a referral—see Referral below.)
Referral: Authorization from a primary care provider for a special-
ist to treat a patient for a specific injury or illness for a specific
number of visits, treatment procedures, and time period.
Utilization Review: Process by which a third-party administrator
determines medical necessity of treatment and approves or
denies payment of health care claims.
Verification: Process of confirming insurance benefits with the
patient’s insurance carrier.
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Current Procedural Terminology
Current Procedural Terminology lists recognized codes for pro-
cedures performed in office and hospital. To order CPT coding
books online, visit https://commerce.ama-assn.org/store/
CPT Sections
■ Evaluation and Management (E/M) (99201–99600)
■ Anesthesia (00100–01999)
■ Surgery (10040–69990)
■ Radiology (70010–79999)
■ Pathology and Laboratory (80048–89399)
■ Medicine (90281–99199)
CPT Modifiers
Modifier Service
-21 Prolonged E/M services
-22 Unusual procedural services
-23 Unusual anesthesia
-24 Unrelated E/M service by the same physician during a
postop period
-25 Significant, separately identifiable E/M service by the
same physician on the same day of the procedure or
other service
-26 Professional component
-27 Multiple outpatient hospital E/M encounters on the
same date
-32 Mandated services
-47 Anesthesia by surgeon
-50 Bilateral procedure
-51 Multiple procedures
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CPT Modifiers—cont’d
Modifier Service
-52 Reduced services
-53 Discontinued procedure
-54 Surgical care only
-55 Postop management only
-56 Preop management only
-57 Decision for surgery
-58 Staged or related procedure or service by the same
physician during the postop period
-59 Distinct procedural service
-62 Two surgeons
-63 Procedure on infants less than 4 kg
-66 Surgical team
-73 Discontinued outpatient procedure prior to anesthesia
administration
-74 Discontinued outpatient procedure after anesthesia
administration
-76 Repeat procedure by same physician
-77 Repeat procedure by another physician
-78 Return to OR for a related procedure during postop
period
-79 Unrelated procedure or service by the same physician
during the postop period
-80 Assistant surgeon
-81 Minimum assistant surgeon
-82 Assistant surgeon (when qualified resident surgeon
not available)
-90 Reference (outside) laboratory
-91 Repeat clinical diagnostic laboratory test
-99 Multiple modifiers
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Common Procedure Codes
Office or Other Outpatient E/M
Procedure Code
New patient 99201–99205
Established patient 99211–99215
Common Outpatient Procedures
Procedure Code
Amniocentesis 59000
Antepartum care (cesarean section) 59510
Antepartum care (vaginal) 59425–59426
Lipid panel 80061
Renal function panel 80069
Hepatic function panel 88076
TORCH antibody panel 80090
Drug screen 80100
Colonoscopy 45378–45387
Complete blood count 85022–85025
Blood glucose (reagent strip) 82948
Glucose tolerance test (GTT) 82950, 82951
Hemoglobin 85018
Blood testing for lead 83655
Blood testing for prostate specific antigen (PSA) 84152
Homocysteine 83090
Injection anesthetic carpal tunnel 20526
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Common Outpatient Procedures—cont’d
Procedure Code
Microhematocrit 85013
Occult blood 82270
Pap smear 88141–88145
Photochemotherapy; ultraviolet 96910
Physical therapy evaluation 97001
Proctosigmoidoscopy 45300
Removal foreign body, intranasal; office 30300
Differential WBC count 85007, 85009
Throat culture 87430
Spirometry 94010
Urinalysis 81000
Urine pregnancy testing 81025
Well child visit V20.2 or
Z00.1 and
E/M code
Routine ECG with at least 12 leads 93000
Tracing only, w/o interpretation or report 93005
Interpretation and report only 93010
Cardiovascular stress test using maximal or
submaximal treadmill or bicycle
93015
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Allergy Testing
Procedure Code
Percutaneous tests (scratch, puncture, prick) w/
allergenic extracts, immed type rxn
95004
Percutaneous tests (scratch, puncture, prick) sequential
and incremental, w/drugs, biologicals, or venoms,
immed type rxn
95010
X-Rays
Procedure Code
Chest, single view, frontal 71010
Chest, 2 views, frontal and lateral 71020
X-ray cervical spine, 2 to 3 views 72040
X-ray thoracic spine, 2 to 3 views 72070
X-ray lumbosacral spine, 2 to 3 views 72100
X-ray eye for foreign body 70030
X-ray mandible, less than 4 views 70100
X-ray nasal bones, minimum of 3 views 70140
X-ray sinuses, less than 3 views 70210
X-ray sinuses, paranasal, minimum of 3 views 70220
X-ray skull, less than 4 views 70250
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Vaccines
Procedure Code
Adenovirus 90476–90477
Anthrax 90581
Chickenpox 90716
Diphtheria, tetanus, acellular pertussis (DTP) 90696
Haemophilus influenza B (Hib) 90645
Hepatitis B 4156F
Human papillomavirus (HPV) 90649
Measles, mumps, rubella (MMR) 90710
Meningococcal 90734
Pneumococcal 90669
Tuberculosis (BCG) 90585
H1N1 (Swine flu) 90663
Alternative/Holistic Medicine
Procedure Code
Acupuncture w/o electrical stimulation 97780
Acupuncture w/electrical stimulation 97781
Chiropractic manipulation 98940, 98941
Osteopathic manipulation 98925
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Hospital E/M Services
Procedure Code
Hospital discharge day management 99238
Office consultations 99241–99245
Initial inpatient consultations 99251–99255
Follow-up inpatient consultations 99261–99263
Confirmatory consultations 99271–99275
Emergency department visits 99281–99285
Common Procedure Codes
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International Classification of Diseases
The International Classification of Diseases (ICD) lists recognized
diagnosis codes for diseases, disorders, and syndromes. The ICD
is updated periodically. The 9th edition with clinical modifica-
tions (ICD-9-CM) was recently updated to a 10th edition (ICD-10).
Transition from ICD-9-CM to ICD-10 will be complete by October
1, 2015.
Using the ICD Diseases Index
Here are basic steps for using the diseases index:
1. Locate the main term in the Index to Diseases (Volume 2).
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.
3. When the condition listed is not found, locate main terms
such as syndrome, disease, disorder, derangement of, or
abnormal.
ICD-9-CM Transition to ICD-10
ICD-9-CM codes were accepted through September of 2015. After
October 1, 2015, only ICD-10 codes are accepted.
Basic steps for using the index also apply to ICD-10; however,
note the alphanumeric chapters below.
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ICD-10 Chapter List
Chapter Blocks Title
I A00–B99 Certain Infectious and Parasitic Diseases
II C00–D48 Neoplasms
III D50–D89 Diseases of the Blood and Blood-Forming
Organs and Certain Disorders Involving
the Immune Mechanism
IV E00–E90 Endocrine, Nutritional and Metabolic
Diseases
V F00–F99 Mental and Behavioral Disorders
VI G00–G99 Diseases of the Nervous System
VII H00–H59 Diseases of the Eye and Adnexa
VIII H60–H95 Diseases of the Ear and Mastoid Process
IX I00–I99 Diseases of the Circulatory System
X J00–J99 Diseases of the Respiratory System
XI K00–K93 Diseases of the Digestive System
XII L00–L99 Diseases of the Skin and Subcutaneous
Tissue
XIII M00–M99 Diseases of the Musculoskeletal System
and Connective Tissue
XIV N00–N99 Diseases of the Genitourinary System
XV O00–O99 Pregnancy, Childbirth and the Puerperium
XVI P00–P96 Certain Conditions Originating in the
Perinatal Period
XVII Q00–Q99 Congenital Malformations, Deformations
and Chromosomal Abnormalities
XVIII R00–R99 Symptoms, Signs and Abnormal Clinical
and Laboratory Findings, Not Elsewhere
Classified
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Continued
ICD-10 Chapter List—cont’d
Chapter Blocks Title
XIX S00–T98 Injury, Poisoning and Certain Other
Consequences of External Causes
XX V01–Y98 External Causes of Morbidity and
Mortality
XXI Z00–Z99 Factors Influencing Health Status and
Contact with Health Services
XXII U00–U99 Codes for Special Purposes
Comparison of ICD-9-CM to ICD-10
ICD-9-CM ICD-10
International Classification
of Diseases, 9th edition:
Clinical Modifications
International Statistical
Classification of Diseases and
Related Health Problems, 10th
edition
Numeric codes except for
V and E codes
All codes alphanumeric with
leading letter indicating chapter/
body system
Factors influencing health
status are V codes
Factors influencing health status
are U and Z codes
External causes of
morbidity and mortality
are E codes
External causes of morbidity and
mortality are V, W, X, and Y codes
Injuries classified by type
(sprain, fracture,
dislocation)
Injuries classified first by site
(wrist, elbow, shoulder)
Codes do not offer
laterality (e.g., Colles’
fracture: 813.41)
Codes indicate laterality (e.g.,
Colles’ fracture Right wrist S52.501
Left wrist S52.502)
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Comparison of ICD-9-CM to ICD-10—cont’d
ICD-9-CM ICD-10
New diseases are added
yearly to the anatomic
section
Letter U is reserved for new
diseases of uncertain etiology
Diseases of the nervous
system and sense organs
are in one chapter
Three separate chapters for
diseases of the nervous system
and sense organs:
Diseases of the Nervous System
Diseases of the Eye and Adnexa
Diseases of the Ear and Mastoid
process
Late effects classified
990–995
Late effects of injury or illness
appear at the end of each
anatomic chapter
Appendix of Mental
Disorders
Appendix of Mental and
Behavioral Disorders
Fourth- and fifth-digit
requirements
Fourth-, fifth-, and sixth-digit
requirements
Common Diagnosis Codes
Disease ICD-9-CM ICD-10
Alzheimer’s disease 331.0 G30.00 early onset
G30.01 late onset
Angina pectoris 413.9 I20.0 unstable I20.1
with spasm
Anorexia nervosa 307.1 F50.0
Appendicitis 540 K35
K35.0 with peritonitis
Asthma, unspecified 493.9x J45.9
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Guidelines for Hypertension Coding
Description ICD-9-CM ICD-10
Hypertension, essential,
or NOS
401 I10
Hypertension with heart
disease
402 I11.0 w/heart failure
I11.9 w/o heart failure
Hypertensive renal
disease
403 I12.0 w/renal failure
I12.9 w/o renal failure
Hypertensive heart and
renal disease
404 I13.0–I13.2
Hypertensive
cerebrovascular disease
430–438 I60.0–I60.9 plus code HTN
Hypertensive
retinopathy
401–405 H35.0
Hypertension secondary 405 I15.0–I15.9
Factors Influencing Health Status and
Contact With Health Services
Description ICD-9-CM ICD-10
Well child visit V20.2 Z00.1
General medical examination adult V70.0 Z00.0
Pre-employment examination V70.5 Z02.1
Sports physical examination V70.3 Z02.5
Blood alcohol and blood drug
testing
V70.4 Z04.0
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ICD-10-PCS
The International Classification of Diseases, 10th edition, Proce-
dure Coding System (ICD-10-PCS) replaces the Procedure section
(volume 3) of the ICD-9-CM. This system contains 7 alphanumeric
characters:
■ Character 1: Section
■ 0: Medical procedures
■ 1: Obstetrics
■ 2: Placement
■ 3: Administrative
■ 4: Measurement & Monitoring
■ 5: Extracorporeal Assistance & Performance
■ 6: Extracorporeal Therapies
■ 7: Osteopathic
■ 8: Other Procedures
■ 9: Chiropractic
■ B: Imaging
■ C: Nuclear Medicine
■ D: Radiation Oncology
■ F: Physical Rehabilitation & Diagnostic Audiology
■ G: Mental Health
■ H: Substance Abuse Treatment
■ Character 2: Body system
■ Character 3: Root operation
■ Character 4: Body region
■ Character 5: Approach
■ Character 6: Device
■ Character 7: Qualifier
Example: The code for extracapsular cataract extraction with
posterior chamber intraocular lens implantation, left eye, is
08RKOJZ:
■ Character 1 is 0 (medical and surgical).
■ Character 2 is 8 (eye).
■ Character 3 is R (replacement).
■ Character 4 is K (lens, left).
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■ Character 5 is O (open).
■ Character 6 is J (synthetic substitute).
■ Character 7 is Z (no qualifier).
Coding Websites
■ World Health Organization ICD-10 search page: http://apps.
who.int/classifications/apps/icd/icd10online
■ Centers for Medicare and Medicaid Services ICD-9 overview:
http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/
■ American Academy of Professional Coders: http://www.
aapc.com
Common Diagnostic Codes
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Important Phone and Fax Numbers
Referring Doctors
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OSHA and Standard Precautions
The Occupational Safety and Health Administration (OSHA) has
mandated various standards to ensure the safety of all health
care professionals and their patients, including disposal proce-
dures and cleaning up spills of biohazardous material.
Disposal Procedures
Proper disposal of contaminated articles is an important compo-
nent of OSHA rules.
Biohazard Container
Regular Waste
Container Sharps 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
Safety Tips
■ Do not recap needles.
■ Keep Material Safety Data Sheets (MSDS) on file.
■ Clean work area regularly with 10% bleach (1 part bleach to
10 parts H2O—for example, add 10 mL bleach to 100 mL
H2O).
■ Try to wash hands in front of patients.
■ When unable to wash hands, use hand sanitizer.
■ All exposures must be reported, documented, and followed
up.
■ Anticipate exposure and wear proper personal protective
equipment (PPE).
CLIN/DX
PROC
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CLIN/DX
PROC
■ Refer to OSHA Website for more information (www.osha.
gov).
Steps for Cleaning up a Biohazard Spill
1. Put on gloves and other PPEs.
2. Contain the spill with paper towels.
3. Cover the spill with 10% bleach solution.
4. Cover it with additional paper towels, if needed.
5. Add more bleach, if needed.
6. Let sit at least 20 minutes.
7. Clean up spill with mechanical device.
8. DO NOT use hands.
9. Dispose of all materials in biohazard container.
10. Clean area again with bleach and dispose of all cleaning
materials in biohazard container.
11. Report and document spill using the incident report
supplied by the office.
Biohazard symbol
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PROC
Patient Interview and Documentation
Proper interview techniques are essential when obtaining a
patient’s medical history and the reason for the appointment.
The following checklist helps ensure that you obtain all the per-
tinent information.
Interview Checklist
____ 1. Ask, “Why are you here today?” or “What brings you
in today?” (Open-ended questions)
____ 2. Ask, “Can you describe the symptoms?”
____ 3. Ask, “When did you first notice these symptoms?”
____ 4. Ask the patient if he or she has any other symptoms,
such as fever, pain, vomiting/diarrhea, difficulty
breathing, persistent cough, or rash.
____ 5 Ask, “Is there anything that makes the symptoms
worse?”
____ 6. Ask, “Have you experienced any recent injuries?”
____ 7. Ask the patient if he or she has any other medical
problems or illnesses.
____ 8. Ask the patient if he or she has taken any prescription
or OTC medications, vitamins, or supplements to
relieve the symptoms. If so, ask what, when, and how
much.
____ 9. Look for observable signs, such as rash, limp, and
wincing.
____ 10. Look for nonverbal cues.
____ 11. Record information in the patient’s own words
whenever possible.
____ 12. ____________________________________________________
____ 13. ____________________________________________________
____ 14. ____________________________________________________
____ 15. ____________________________________________________
____ 16. ____________________________________________________
____ 17. ____________________________________________________
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CLIN/DX
PROC
Suggested Responses to Patients
■ “I understand that this is a very tough time for you.”
■ “Is there anyone I can call for you?”
■ “Is there anything I can do for you?”
■ “I’ll see if I can help you with that.”
■ “It is recommended that you do it this way.”
■ “Would you like me to repeat the instructions?”
Pain Assessment Checklist
_______ 1. How severe is the pain? (Scale of 1 to10)
_______ 2. Is the pain dull or sharp?
_______ 3. When did you first notice the pain? (Onset)
_______ 4. Did pain come on suddenly?
_______ 5. What were you doing when you first noticed the
pain?
_______ 6. Duration of pain? Constant or intermittent?
_______ 7. Location of pain?
_______ 8. What makes pain worse? (Movement, sitting, and
so forth)
_______ 9. What makes pain better?
_______ 10. Taken anything for pain? If so, what was taken?
(Dosage and frequency of dosage)
_______ 11. Did pain medication ease the pain?
_______ 12. _________________________________________________
_______ 13. _________________________________________________
_______ 14. _________________________________________________
_______ 15. _________________________________________________
_______ 16. _________________________________________________
_______ 17. _________________________________________________
_______ 18. _________________________________________________
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PROC
Vital Signs
Vital signs are important indicators of body function. Accurate
measurement and documentation of a patient’s vital signs is an
essential skill for medical assistants.
Average Normal Ranges for Vitals
Age
Temp
(°F)
Pulse
(beats/min)
Resp
(breaths/min) BP
Newborn* 97–100 80–160 30–60 74/50–100/70
Child
(1–5 yrs)
98.6 80–130 20–30 80/50–112/80
Child
(6–16 yrs)
98.6 75–110 15–23 80/50–120/80
Adult 97–99 60–100 12–20 90/60–120/80
* Ranges should be used as a reference only. Normal ranges, especially for
newborns and children, can vary.
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Temporal
Carotid
Brachial
Radial
Femoral
Dorsalis
pedis
Posterior
tibial
Popliteal
Pulse points
Vital Signs Basics
Temperature Basics
■ Temperature increases with infection, exercise, crying, and
pregnancy.
■ Temperature is decreased in morning.
■ For rectal temperature, subtract 1 degree.
■ For axillary temperature, add 1 degree.
■ Note method of temperature assessment, such as oral,
rectal, axillary, or aural.
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Pulse Basics
■ Pulse increases with physical activity, pain, anxiety, fever,
pregnancy, and certain medications.
■ Pulse is decreased in elderly and with certain medications.
■ Note pulse rhythm and volume.
Respiration Basics
■ Respiration increases with physical activity, anxiety, certain
medications, and fever.
■ Respiration is decreased in elderly and with certain
medications.
■ Note respiratory rhythm and depth.
■ Note abnormal breath sounds, if any.
■ Take respiration rate without the patient knowing.
Blood Pressure Basics
■ BP increases with physical activity, anxiety, stress, smoking,
and certain medications.
■ BP decreases with certain medications.
■ Make sure cuff is correct size for patient.
■ Never hold bell with thumb.
■ Position cuff so scale is easily visible.
■ Position patient’s arm at heart level and support the arm.
■ Wait 1 to 2 minutes before repeating BP.
■ Note arm (L or R) and patient position (sitting or lying).
Documentation
Proper documentation techniques are essential when recording
patient information. Here are tips to remember when document-
ing entries in a patient’s chart.
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General Charting Guidelines
■ Always use blue or black ink.
■ Chart immediately after procedure is complete.
■ Write legibly.
■ When charting CC, try to use patient’s own words.
■ Begin new entry on new line.
■ Begin entry with date and time.
■ Be accurate and specific.
■ Use standard abbreviations.
■ Never erase an entry; correct errors in charting appropriately.
■ Always sign your entry with your name and title.
Charting Examples
11/03/16; 9:00
a.m.
CC: pt c/o sore throat and fever of 102°F
X3 days. Pt states it’s difficult to swallow.
Took ibuprofen 400 mg q8hr last 2 days.
—————————————C. Chapin, CMA
11/03/16;
9:30 a.m.
Rapid strep: positive.———C. Chapin, CMA
7/17/16; 1:30 p.m. CC: pain and numbness in L leg and foot
for 1 week. Pain worse when sitting or lying.
Patient states a “10” on the pain scale.
Taken ibuprofen 400 mg q6hr with no
relief. No recollection of actual back
injury.———————–——-C. Chapin, CMA
Blank Charting Box
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Documenting Using SOAP Method
Many offices use the SOAP method for a more efficient way of
charting. SOAP stands for:
■ Subjective patient information, which consists of the
symptoms only the patient can feel.
■ Objective patient information, which consists of the
observable symptoms, such as a rash, or measurable
finding, such as vital signs.
■ Assessment, which is when the physician forms a diagnosis
based on the subjective and objective information.
■ Plan, which is then formulated by the physician and may
include further laboratory tests or treatments.
Transcription Entry
Stacy James
Date of Birth: 05/11/94
Visit Date: 07/11/15
S: Patient complains of sore throat, swollen glands, and
extremely tired for 5 days.
O: Laboratory results: rapid strep: negative. Upon examination
physician observes splenomegaly temp 100.4°F.
A: Physician orders CBC, Mono Test, and LFT.
P: Bed rest, no physical activity for 6 weeks.
Progress Notes in Patient’s Chart
Progress Notes
Patient Name: James, Stacy D.O.B. 05/11/90
Chart # 739410
Date S O A P
07/11/15 Patient complains of sore throat, swollen glands, and
feeling exhausted for 5 days.
T: 100.4, rapid strep: negative, abdominal exam
reveals splenomegaly.
Order CBC, Mono Test, and LFTs
Bed rest, no physical activity for 6
weeks.
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CLIN/DX
PROC
Assisting With the Physical Examination
1. Wash hands.
2. Prepare examination room.
3. Gather supplies:
a. Gown or drape
b. Gloves
c. Ophthalmoscope
d. Otoscope
e. Percussion hammer
f. Tongue depressors
g. Laboratory supplies, such as sterile container, lancets,
and so forth
4. If routine urinalysis is needed, instruct patient on proper
CVMS collection.
5. Obtain and chart patient’s height and weight.
6. Obtain and chart patient’s vitals.
7. Obtain current medical history and present illness (PI).
Record all pertinent information.
8. Instruct patient regarding disrobing and gowning and
assuming a sitting position.
9. Inform patient that physician will be right in.
10. Assist physician with positioning patient during
examination.
11. Pass supplies and instruments as requested by physician.
12. Perform various tests as requested by physician.
13. Provide patient education as needed.
14. Clean room after patient leaves.
Notes
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PROC
Positioning Chart
POSITION USE
90˚
angle
Sitting Position
Sitting Examination of head, neck, chest, heart, lungs,
back, and arms.
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Supine Position
Supine (Recumbent) Examination of head, neck, chest,
heart, abdomen, legs, and arms.
Prone Position
Prone Examination of back and feet.
Lithotomy Position
Lithotomy Gynecological examination
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PROC
Dorsal Recumbent Position
Dorsal Recumbent Examination of head, neck, chest, and
heart. May be used for gynecological
examination.
45˚
angle
Semi-Fowler’s Position
Semi-
Fowler’s
Examination of head, neck, chest, and heart. For
patients with breathing or back difficulties.
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PROC
Sims’ (left lateral) Position
Sims’ Examination of anal and rectal areas; proctological
procedures.
Knee-Chest Position
Knee-Chest Examination of anal and rectal areas; proctological
procedures.
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General Clinical Office Tips
Things to do before the office opens:
_____1. Clean all examination rooms.
_____2. Make up 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.
Things to do before the office closes:
_____1. Pull charts for 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.
Notes
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PROC
Gynecology and Obstetrics Exams
Gynecology
Supplies
■ ThinPrep container or frosted glass slide
■ Cervical scraper, cytobrush, and/or cotton-tipped applicator
■ Spray fixative
■ Cytology request form
■ Speculum
■ Gloves
■ Lubricant
■ Examination gown
■ Tissues
■ Slide holder
■ Culture swab, if needed for culture
■ Laboratory requisition slip, if needed for culture
Patient Prep
■ Obtain vitals, weight, and patient history, including last
menstrual period (LMP).
■ Ask patient if she needs to void.
■ Give patient gown or drape and instruct her to remove all
clothing.
■ For breast examination, put patient in supine position.
■ For pelvic examination, put patient in lithotomy position,
with feet in stirrups and buttocks at edge of table.
■ Hand physician supplies as needed.
■ Label all specimens completely and accurately.
■ Complete all required requisition slips.
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Wet Prep Procedure for Trichomonas
■ Obtain clean glass slide.
■ Place a drop of saline onto slide.
■ Obtain swab of vaginal discharge.
■ Mix discharge with saline on slide.
■ Cover slip and examine under microscope.
Trichomonas Slide
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PROC
KOH Prep for Candida
■ Obtain clean glass slide.
■ Obtain swab of vaginal discharge.
■ Place discharge on slide.
■ Add drop of KOH.
■ Apply cover slip to slide and examine under microscope.
Candida Slide
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PROC
Obstetrics
Components of First Prenatal Visit
■ Complete medical history, including LMP, obstetric history
■ Calculate due date
■ Full breast, pelvic, abdominal, and rectal examinations
■ Vitals
■ Weight
■ Laboratory tests
■ CBC
■ Urinalysis
■ Rubella
■ RPR
■ Blood type and Rh
■ PAP smear
■ Tests for chlamydia, gonorrhea, and group B beta
streptococcus
■ Hepatitis B and HIV (highly recommended)
■ Patient education
Calculating Due Date
Naegele’s rule
LMP + 7 days – 3 months + 1 year
7 17 2014
3 7 1
4 24 2015
( )
( )
LMP
Due date
− + +
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PROC
Return Prenatal Visits
■ Vitals and weight
■ Urinalysis, especially protein and glucose
■ Fundal height measurement
■ Fetal heart tones
■ Ultrasound
■ Abdominal and/or transvaginal
■ Patient needs to drink 32 oz H2O 1 hr before test
■ Amniocentesis (if indicated)
■ Approx. 15 to 18 weeks
■ >35 yrs old
■ High-risk pregnancy
■ Laboratory tests
■ AFP (approx 15 to 20 weeks)
■ 1 hour GTT (approx 24 to 28 weeks)
■ Chorionic villus sampling
Postpartum Visit
■ Vitals
■ Weight
■ H and H
■ PAP smear
■ Breast and pelvic examinations
■ Discussion of birth control
Pediatrics Exams
Health Maintenance Visits
■ Usual schedule: 1 mo, 2 mo, 4 mo, 6 mo, 9 mo, 12 mo,
15 mo, 18 mo, 2 yr, every year thereafter
■ Weight, length (height), head circumference
■ Complete growth charts
■ Anticipatory guidance
■ BP age 3 and older
■ Laboratory tests, such as PKU, urinalysis, Hgb, cholesterol,
and lead
■ Immunizations
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PROC
Sick Child Visits
■ Temperature
■ Blood pressure
■ Weight
■ Signs and symptoms
■ Physician examination
Tips on Working With Infants and Children
■ Carry infant properly.
■ Gain trust of child and parents.
■ Be honest with child; never say “It won’t hurt.”
■ Use language child can understand.
■ Demonstrate procedures with doll or stuffed animal.
■ Be patient with child, use calm tone of voice.
■ Involve children as much as possible in procedure, such as
letting them touch or use stethoscope before using it on them.
■ Help child overcome his or her fears.
■ During well and sick visits, observe for signs of abuse, such
as bruises, burns, or other unexplained injuries.
GI Procedures
Fecal Occult Blood
Patient Prep
■ Patient must follow pretesting instructions and diet
restrictions completely.
■ Emphasize importance of precisely following these
instructions.
■ Patient must follow a high-fiber, no-red-meat diet for 2 days.
■ Patient should discontinue certain medications that can
interfere with testing.
■ False-positive results can occur with aspirin or iron
supplements.
■ False-negative results can occur with consumption of
vitamin C.
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■ Stool specimens should not be collected during
menstruation or while hemorrhoids are bleeding.
■ Show collection kit to patient and explain procedure for
collection of stool specimen.
■ Remind patient to keep occult blood card out of direct
sunlight.
■ Emphasize that three different specimens must be collected
for testing.
■ Once the three sections of the card have been filled up,
instruct patient to put the card in the envelope provided in
kit. Emphasize that only this special envelope can be used.
■ Once card has been received by office, test according to
manufacturer’s specifications. Record results in patient’s chart.
Positive and Negative Occult Blood Test Results (From
Strasinger SK, DiLorenzo MS. The Phlebotomy Textbook, 3rd
ed. F.A. Davis, Philadelphia, 2011.)
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Patient Prep for Colonoscopy
■ A clear liquid diet the day before examination. Clear liquids
include: broth, JELL-O (not red, purple, or blue), Gatorade/
Powerade (not red, purple, or blue), non-dairy–based orange
or lime sherbet, white grape juice (or any clear juice), plain
tea or coffee, Popsicles (again, no red, purple, or blue).
■ Patient will be instructed to drink a colon cleansing prep the
day before the examination. Common ones are MiraLAX or
Gatorade based. For better drinking results, keep the prep in
the refrigerator. There are also preps in pill form. Make sure
you explain to the patient that not all insurance policies will
pay for the pill preparation, and they should check with their
insurance company before selecting a prep.
■ It is very important to consult the office protocol regarding
specific patient preparation.
Eye and Ear Exams
Visual Acuity Testing for Distance
■ Use Snellen’s eye chart composed of letters, capital E
letters, or pictures.
■ Select proper chart based on age and development of
patient.
■ Explain procedure to patient.
■ Give patient eye occluder and tell patient to hold over
nontested eye and not to close or squint that eye.
■ Have patient stand 20 feet from eye chart.
■ If patient wears glasses or contacts, he or she should wear
them for the examination.
■ Usually test right eye first, then left eye.
■ Have patient start with the 20/70 line and continue down
each line.
■ The number to the side of the smallest line is the patient’s
results for that eye.
■ Repeat with left eye.
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PROC
1
2
3
4
5
6
7
8
200 FT
61 M
0
10
˚
2
0
˚
3
0
˚
4
0
˚
50˚
60˚
70˚ 80˚ 100 110˚ 120˚ 130˚
1
4
0
˚
1
5
0
˚
1
6
0
˚
17
0˚
180˚
90˚
100 FT
30.5 M
70 FT
21.7 M
50 FT
15.2 M
30 FT
9.1 M
20 FT
6.1 M
15 FT
4.6 M
10 FT
3.0 M
20
200
20
100
20
70
20
60
20
30
20
20
20
20
20 FT
6.1 M
20
15
20
10
Rotating “E” Snellen Chart (From Eagle S, Brassington C,
Dailey C, Goretti C. The Professional Medical Assistant. F.A.
Davis, Philadelphia, 2009; 764, with permission.)
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CLIN/DX
PROC
Near Visual Acuity Testing
■ Obtain test card.
■ Have patient hold card 14″ to 16″ away from the eyes.
■ Test both eyes as you would for Snellen’s test.
■ Have patient read out loud each line or paragraph.
■ Note and record smallest line the patient can read
comfortably without squinting or other difficulties.
Ishihara Test for Color Vision
■ Use Ishihara color plates.
■ Test patient using all 14 color plates.
■ Ask patient to identify the numbers formed by the colored
plates.
Interpretation of Results:
Normal color vision = 10 or more plates read correctly
Color vision deficiency = 7 or fewer plates read correctly
Eye Irrigation
Eye irrigation is used to wash out foreign particles or chemicals
or to apply antiseptic solution.
■ Use proper irrigation solution as prescribed by physician.
■ Warm solution if required.
■ Obtain all supplies needed:
■ Gloves
■ Basin
■ Towel
■ Syringe or bulb
■ Normal saline or other prescribed sterile irrigation solution
■ Put patient in sitting or lying position, with head tilted
toward the affected eye.
■ Place towel on patient’s shoulder.
■ Have patient hold basin to catch fluid.
■ Fill irrigation syringe or bulb with solution.
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PROC
■ Hold eye open and carefully direct the stream of irrigant
from the inner to outer canthus of the affected eye, being
careful not to touch the syringe to the eye.
■ Repeat as needed.
Eye Instillation
Eye instillation is used to administer medication or normal saline.
■ Use proper medication as prescribed by physician.
■ Put patient in sitting position, instruct patient to tilt head up
slightly and to look up.
■ If using sterile eyedropper, draw up required amount of
solution needed.
■ Carefully pull down the lower conjunctival sac and instill the
required number of drops into the sac, being careful not to
touch the eye with the dropper.
■ Instruct patient to close eye gently for a few seconds, but to
not squeeze shut.
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PROC
Ear Irrigation
Ear irrigation is used to clean out wax, a foreign body, or
discharge.
■ Use proper irrigation solution as prescribed by physician.
■ Warm solution if required.
■ Obtain all supplies needed:
■ Gloves
■ Basin
■ Towel
■ Syringe or bulb
■ Normal saline or other prescribed irrigation solution
■ Put patient into the sitting position and place towel on
patient’s shoulder.
■ Have patient hold basin to catch draining fluid.
■ Have patient tilt head toward the affected ear.
■ Fill syringe with required amount of solution.
■ Gently pull ear upward and backward for an adult and down
and backward for a child.
■ Insert the syringe into the ear and position the flow of the
solution toward the roof of the ear canal, never directly
irrigating the tympanic membrane.
■ Refill syringe and repeat irrigation as needed.
Ear Instillation
Ear instillation is used to administer medication or normal saline.
■ Use proper medication as prescribed by physician.
■ Place patient in lying position, with affected ear facing up.
■ Gently pull ear upward and outward for adults and
downward and outward for children ages 3 years and
younger.
■ Hold the tip of the dropper to the opening of the ear canal
and instill the prescribed number of drops.
■ Have patient stay in position for 2 to 3 minutes to allow
medication to disperse completely.
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PROC
Electrocardiography
Chest Lead Placement
1
2
3
4 5 6
V1 V2 V3
V4
V5
V6
Midclavicular
line Anterior
axillary line
Midaxillary
line
Lead Placement
V1 4th
intercostal space to the right of the sternum
V2 4th
intercostal space to the left of the sternum
V3 Halfway between V2 and V4
V4 5th
intercostal space in the left midclavicular line
V5 Lateral to V4, in the left anterior axillary line
V6 Lateral to V5, in the left midaxillary line
NOTE: V4, V5, and V6 should be placed along horizontal line, not necessarily
following intercostal space.
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Limb Lead Placement
RA and LA—anterior surface of the upper arms
RL and LL—clean, dry, fleshy areas of the lower legs.
Normal Cardiac Cycle
P-R
segment
P wave
S-T
segment T wave U wave
P-R interval
QRS
complex
Q
wave
S wave
Q-T interval
R
Normal Rhythm Strip
Types of Artifacts
■ Somatic tremor: muscle movement or spasm
■ Electrical interference: ECG machine too close to another
electrical machine or instrument
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■ Baseline interruption: lead comes off body or broken lead
■ Wandering baseline: poor skin connection or loose electrode
Basic ECG Procedure
1. Wash hands and assemble supplies.
2. Greet and identify your patient, introduce yourself, and
explain the procedure.
3. Instruct the patient to remove socks or panty hose and
clothing above the waist, including undergarments.
4. Assist the patient as necessary.
5. Position the patient on the examination table in the supine
position. Drape for privacy.
6. Turn on the machine. Enter the patient’s name, date, time,
and patient’s current cardiac medications into the machine
or write the information on the tracing.
7. Clean the patient’s skin with alcohol at each site where an
electrode will be placed and clip hair if necessary.
8. Apply self-adhesive electrodes to a dry, clean, intact, fleshy
area on the extremities across from one another and to the
cleaned areas on the chest. Connect the lead wires to the
electrodes using the alligator clips. Make sure the correct
leads are connected to the correct electrodes. Do not cross
lead wires.
9. Press the AUTO button on the ECG machine. The machine
runs automatically once the AUTO button is pressed.
Watch for artifacts and make corrections as needed to get
an acceptable tracing.
10. Disconnect the lead wires from the electrodes and then
remove the electrodes from the patient.
11. Assist the patient off of the examination table and with
dressing as needed.
12. Clean and return the ECG machine to storage.
13. Mount the ECG tracing in the patient’s chart or give it to
the physician as directed.
14. Document the procedure in the patient’s chart.
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PROC
Holter Monitor
Supplies
■ Electrodes
■ Portable tape recorder
■ Holder and belt
Patient Prep
■ If patient is not wearing a shirt that opens in the front, give
him or her a cape and instruct to put on with opening in the
front.
■ Prepare skin before attaching electrodes.
■ Apply electrodes to chest.
■ Tell patient he or she will wear monitor for 24 hours.
Patient Education
■ Instruct patient to:
■ Keep electrodes dry.
■ Keep electrodes in place; do not move them.
■ Keep diary of date, time of day, symptoms, emotional
states, activities, and medications.
■ Activities include but are not limited to walking,
housecleaning, yard work, and sexual activity.
■ Press event marker if any chest pain is experienced but do
not overuse the marker.
■ Do not use electric blanket.
■ Return to office 24 hours later.
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PROC
Holter Monitor Lead Placement*
1
3
5 4
2
# Channel Color Lead Placement
1 1(−) yellow LA Below left clavicle, just
lateral to the midclavicular
line.
2 2(−) white RA Below right clavicle, just
lateral to the midclavicular
line.
3 3(−) blue Sternum At manubrium sterni.
4 3(+) red Mod V4 At the sixth rib on the
midclavicular line.
5 Reference green Reference Lower right chest wall, rib.
Please note, each Holter monitor may be a little bit different and have more or
fewer leads than displayed on this example. Always read the user’s manual
before placing a Holter monitor on a patient.
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PROC
Spirometry
Patient Prep
■ Stress importance of following instructions exactly.
■ Demonstrate procedure for patient.
■ Position patient according to requirements of the individual
spirometer (seated or standing).
■ If nose clip is required, instruct patient how to apply.
Procedure
■ Program machine with patient’s information.
■ Instruct patient to take a deep breath and then securely
cover mouthpiece with mouth.
■ Tell patient to exhale forcefully into the mouthpiece and not
to stop until you tell him or her.
■ Coach patient while he or she is exhaling.
■ Most spirometers will note if test was adequate. If
inadequate, test must be repeated.
■ Usually three acceptable readings are performed.
Pulse Oximeter
■ Measures patient’s arterial blood oxygen saturation level.
■ Sensor clip is attached to patient’s finger, toe, or ear.
■ Used on patients with pneumonia, CHF, COPD, emphysema,
asthma, etc.
■ Movement, fingernail polish, weak pulse can affect accuracy.
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