Suffixes and Prefixes in Medical Terminology, Exams of Nursing

Download Suffixes and Prefixes in Medical Terminology and more Exams Nursing in PDF only on Docsity! FBLA Health Care Administration (1300 Questions and Answers).2024 LATEST UPDATE BEST GRADED A+ A health record can be defined as written or graphic information documenting facts and events during the rendering of patient care. Either paper or electronic format. - SOLUTION health record encourages implementation by offering five annual financial incentives for qualifying offices that convert to an electronic format beginning in 2011 and ending in 2015 or 2016. - SOLUTION American Recovery and Reinvestment Act of 2009 (ARRA) Health record content (common) - SOLUTION 1. Patient registration (demographic information) 2. Medication record 3. history and physical exam, notes or report 4. Progress or chart notes 5. Consultation reports 6. imaging and x-ray reports 7. Laboratory reports 8. Immunization record 9. Consent and authorization forms 10. Operative report 11. Pathology report. In hospital setting would also include - attending physician's orders - date of admission - hospital stay dates - discharge date - discharge summary What types of systems are used in electronic health record system (EHR) - SOLUTION 1. problem-oriented record (POR system) 2. source-oriented record (SOR system or integrated system) consists of: flow sheets, charts, or graphs, that allow aphysician to quickly locate information and compare eaulation - SOLUTION Problem-Oriented Record System (POR) documents are arranged according to sections (e.g., H&P section, progress notes, lab tests, radiology reports, or surgical operations) SOR system filed in reverse chronological order. More difficult to locate data due to scattering throughout - SOLUTION Source-Oriented Record system (SOR) collection of medical information about the past, present and future of a patient that resides in a centralized electronic system. - SOLUTION Electronic Health Record System Difference between an EHR and an EMR - SOLUTION : An EMR is individual physician's EMR for the patient, including medical history, allergies, and appointment information. An EHR is all patient medical information from many information systems, including all components of the EMR. Advantages of EHR - SOLUTION 1. no physical space required 2. abstracting data is eliminated except when free-form documentation such as narrative notes, dictations, and natural language processing is used. 3. free-text approach, encourages use of abbreviations or fewer spelled out words may result in scant or undecipherable documents. 4. Electronic systems have built in security safeguards to protect against improper disclosure, unauthorized access, or unintended alteration of information for both the data and the system. 5. ARRA requires covered entities to notify individuals if their protected health information is accessed or disclosed in an unauthorized manner. Systemized Nomenclature of Medicine for Clinical Terminology. Medical terminology cassification system that codes text data in an EHR system will assist in standardizing clinical medical terminology - SOLUTION SNOMED- CT created the Commission on Systemic Interoperability to develop a strategy to make health care information abailable at all times to patients and physicians. Goal by 2014. - SOLUTION Medicare Modernization Act e. Execution of the physician's written instructions by a patient care-giver. - SOLUTION Five reasons for legible documention: Evaluation and management, occurs in office visit, inpatient hospital facilities, and nursing homes - SOLUTION E/M Current Procedural Terminology - SOLUTION CPT Centers for Medicare and Medicaid Services. - SOLUTION CMS Developed documentation guidelines for CPT E/M services. - SOLUTION American Medical Association and Centers for Medicare and Medicaid Services. also called fiscal intermediaries, fiscal agents, and fiscal carriers, conduct reviews for irregular reporting patterns. HAVE WALK IN RIGHTS, access to a medical practicde w/o apptment or search warrant. - SOLUTION Medicare administrator contractors Documentation must support the level of service and each procedure rendered. - SOLUTION Third-party payers and federal programs have responsiblity to ensure that professional services provided to patients were medically mecessary criterion used by insurance companies, as well as federal programs, when making decisions to limit or deny payment. Payment may be delayed, downcoded or denied if the medical necessity of a treatment is questioned. - SOLUTION medical necessity Insurers differ on definition and may not cover services depending on the benefits of the plan. - SOLUTION Good medical practice standards Advance beneficiary Notice of Noncoverage, also know as waiver of liability agreement or responsibility statement - SOLUTION ABN If provider has submitted insurance claims for payments deemed fraudulent or inappropriate by government. - SOLUTION Audit A point system used while reviewing each patient's health record during the performance of an audit. Points award only if documentation is present for elements required in health record. Point system is used to show where deficiencies occur in health record documentation, evaluation and substantiate proper use of diagnostic and procedural codes.l - SOLUTION External Audit Point System HMO, PPO, private carriers can claim refunds Medicare has power to levy fines and penalties and exclude providers from Medicare program - SOLUTION consequences of accidental (or intentional) miscoding. If it is not documented, then it was not performed. (have right to deny reinbursement) - SOLUTION Insurance carrier and documentation prepayment and postpayment audits to monitor accuracy physicians' use of medical services and procedure codes. - SOLUTION Medicare carriers frequent audits a. billing intentionally for unnecessary services b. billing incorrectly for services of physican extenders (NPP) C. billing for diagnostic tests w/o separate report in health record d. changing DOS on insurance claims to cmply with policy coverage dates e. waiving copayments or deductibles, or allowing other illegal discounts f. ordering excessive diagnostic tests g. using 2 different provider numbers to bill the same services for same patient h. failing to return overpayments made by the Medicare program i. misusing prover ID number j. using improper modifiers for financial gain - SOLUTION Billing Patterns causing possible audits 1. The health record should be accurate, complete (detailed), and legible. 2. Documentation of each patient encounter includes or provide reference to following: a. chief complaint or reason for encounter b. relevant history c. physical examination d. findings e. prior diagnostic test results f. assessment, clinical impression, or diagnosis g. plan for care h. date and eligible identity of the health care professional 3. The reason for encounter stated 4. Past and present diagnoses 5. Appropriate health risk factors should be identified 6. The patient's progress, response to and changes to treatment, planned follow-up care and instructions and diagnosis should be documented. 7. Patient refusal to follow medical advise 8. Procedure and diagnostic codes reported on the insurance claim form or billing statement supported by documentation. 9. Confidentiality of health record maintained 10. Each chart entry dated - SOLUTION Common Medical Office Documents/ Documentation guidelines for Medical Services Degree of documentation depends on the complexity of the service and the specialty of the physican. history, examination, medical decision making - SOLUTION Contents of a Medical Report includes: chief complaint (CC), History of Present Illness (HPI), review of systems (ROS), past history, family, or social history (PFSID) extent of each depends on present problems - SOLUTION Documentation of History concise statement usually in patient's own words describing symptom, problem, condition, diagnosis, physician-recommended return, or other factor. REQUIRED FOR ALL LEVELS OF HISTORY: - SOLUTION Chief complaint (CC) chronological description of development of the patients present illness from first sign or symptom or from previous encounter to present (may include one or more of the following): 1. location, 2, Quality/Character of the symptom/pain, 3. severity or degree (1-10), 4. Duration, 5. Timing, when, 6. Context - situation associated with symptom 7. Modifying factors that make it better or worse, 8. Associated signs and symptoms - SOLUTION History of present illness (HPI) Inventory of body systems obtained through a series of questions that is used to identify signs or symptoms patient might be experiencing or has (e.g., a patient who has received treatment for a condition and is then referred by the physician to a second physician for treatment for the same condition), - SOLUTION continuity of care intensive care provided in a variety of acute life-threatening conditions requiring constant "full attention" by a physician. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition. - SOLUTION Critical care it may be given by the physician in a hospital ED or in a physician's office setting. Emergency care is that is provided to acutely ill patients and may or may not involve organ system failure, but does require immediate medical attention. - SOLUTION Emergency care medical condition that manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediately medical attention could reasonably be expected to result in placing the patients health in serious jeopardy, serious impairment to body functions, or serious dysfunction of any body organ or part. - SOLUTION Emergency medical condition as defined by Medicare Any medical condition of a recent onset and severity , including but not limited to severe pain, that would lead a produent lay person, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injry is of such a nature that failure to obtain immediate medical care could result in placing the patient's health in serious jeopardy, seirous impairment to bodily functions, or serious dysfunction of bodily organ or part - SOLUTION Lay person definition of an emergency discussion with a patient, family, or both concerning one or more of the following: diagnostic results, impressions, or recommended diagnostic studies; prognosis; risks and benefits of treatment options; instructions for treatment or follow-up; importance of complication with chose treatment options; risk factor reduction, and patient and family eduction. - SOLUTION Counseling impression - SOLUTION imp diagnosis - SOLUTION dx should be eliminated from vital sections of health record, such as final diagnosis, operative notes, discharge summaries, and descriptions of special procedures - SOLUTION AMA policy on abbreviations term including the name of a person (e.lg. Graves' disease)) s hould not be used when a comparable anatomic term can be used in its place ex. "Buerger's disease compared to thromboangitis obliterans - SOLUTION eponym. a condition that runs a short but relative severe course - SOLUTION acute a condition persisting over a long period of time - SOLUTION chronic problems can occur with documentation because of missing or misused essential words (ex. diastolic dysfunction instead of heart failure due to diastolic dysfunction - SOLUTION diagnostic terminology and abbreviations may not support billing of services, instead, documentation must indicate exatly which limb was examined and abbreviated wording would not pass an audit. "CANNED" notes mean no assessment was actually performed, this is fraud. - SOLUTION within normal limits (WNL), noncontributroy, negative/normal, other than the above, all systems were normal ex. chest x-ray report reviewed, or read instead of "chest x-ray negative" - SOLUTION Detailed documentation justifies billed services by providing verification a) preoperative vs postoperative, (b) simple/intermediate/complex (c) undermining (d) take down (e) lysis of adhesion (f) surgical position (g) surgical approach (ex. vaginal vs. abdominal - SOLUTION surgical terminology (preop) period before a surgical procedure, begins with the first preparation to a patient fore surgery and ends with anestheia in operating room - SOLUTION preoperative (PO) period of time after surgery, beginning with patient emerging from anesthesia and continues through time required for acute effects of anestheia and surgical procedures to decrease - SOLUTION postoperative (example, repair of lacerations) listed as simple, intermediate or complex repairs. Documentation should liste the length (in centimeters) of all incisions and layers of involved tissues sothat correct procedure codes for excision of lesions and type of repair can be determined. - SOLUTION surgical procedures for integumentary system one layer closure - SOLUTION simple laceration (superficial) requires layered closure of one or more of the deeper layers of the skin and tissues - SOLUTION intermediate laceration require more than layered closure and may require reconstructive surgery - SOLUTION complex lacerations Document length of time spent on procedure, especially if of unusual duration such as prolonged services, counseling, or team conferences. Stated somewhere in the report. - SOLUTION If time is factor in coding for reimbursement. document - SOLUTION State of art equipment therapeutic or cosmetic procedures - SOLUTION Surgical procedures one of two categories cut in a horizontal fashion - SOLUTION undermining to take apart - SOLUTION take down destruction of scar tissue - SOLUTION lysis of adhesions - bilateral ( pertaining to both sides) - blood loss of more than 600 ml (severe bleeding) - complete or total (entire or whole) - complicated by (involved with other situations at the same time) - hemorrhage (escape of blood from vessels; bleeding) - initial: (first procedure or service) 4. confirm the fax arrived at destination - SOLUTION Fax transmissions for insurance claims from legal standpoint, protecting patient's confidentiality in fax process crucial. PATIENT MUST SIGN AUTHORIZATION TO RELEASE INFORMATION VIA FAX. fax machines should be in secure, private location. a cover sheet always used containing recipient name, sender, date, total of pages, fax telephone numbers, a statement of personal, priviledged and confidential medical information intended for the named recipient only. with request that authorized receiver sign and return attached receipt form at bottom of cover letter. use coded reference number - SOLUTION Sensitive information do not use fax machines routinely 1. hand or mail delivery will not meet needs of immediate patient care 2. required by a third party for ongoing certification of payment for hospitalized patient - SOLUTION AHIMA vs fax machine 1. STD, HIV, Alcohol or drug treatment . Psychiatric and psychotherapy records, patient financial data - SOLUTION do not fax verify fax was received or ensure fax received at destination or run log from fax machine - SOLUTION transmittal verification / check with medicare fiscal intermediarey as to acceptability in faxing - SOLUTION Medicare fax policy under penalty - writ requiring the appearance of a witness at a trial or other proceeding, see details on pp 118-120 - SOLUTION subpoena requires witness to appear an dbring or send certain records in his possession - SOLUTION subpoena duces tecum protected health information - SOLUTION PHI electronically store information - SOLUTION ESI concern that they may be altered, overwritten without leaving any evidence, or stored in several computer systems. Metadata or supportive data that is information on the computer system about the medical data, - SOLUTION ESI issues supportive data that is information on the computer system about the medical data such as - substantive data is application based and may contain modifications, edits, or comments - system-based data includes author, date and time when the entry was created, and date of modification - embedded data is text, numbers, content direcdtly imput but not visible on output (eg., spreadsheet formulas or hyperlinks) - SOLUTION Metadata subpoena issued by notary public - SOLUTION notary subpoena preservation of health records governed by federal, state and local laws. see pp 120 - SOLUTION retention of records proof materials for the establishment of evidence should be kept indefinitely in event of legal inquiry. Calendars, appointment books and telephone logs also should be filed and stored. - SOLUTION Federal False Claims Act makes requests for electronic data a standard part of the discovery process during federal lawsuits including health, accounting phone, instant messaging and electronic mail that might be needed for future litigation - SOLUTION Federal Rules of Civil Procedure kept for at least 6 years from date of creation - SOLUTION HIPAA NPP acknowledgements physican may terminate a contract - sending a certified letter of withdrawal to patient (if refused by patient, file returned letter in patient's chart) - sending a certfieid letter of confirmation of discharge when patient states that he or she no longer desires care - send letter confirming that the patient left the hospital against medical advise or the advise of physician, UNLESS signed statement in patient's hospital records - SOLUTION Termination of a case see box 4-1 on pp 124-125 - SOLUTION Prevention of legal Problems every patient seen by physician must have comprehensive legible documentation about what occurred during the visit for the following reasons; (1) avoidance of denied or delayed paments 2. enforcement of medical record keeping rules by insurance carriers 3. suppoena of health record by state investigators or the court for review 4. defense of a professional liability claim - SOLUTION Reasons for proper medical record Documentation (four) foremost tool of clinical care and communication - SOLUTION Electronic health record as tool HIPAA directs adoption of national electronic standard - SOLUTION Medical records evolving into electronic media ensures that services paid for have been provided and were medically necessary and that documentation must support the level of service and each procedure rendered - SOLUTION CMS introduced documentation guidelines to Medicare carriers show where deficiencies occur in health record documentations and substantiantes proper use of diagnostic and procedure codes - SOLUTION External and internal audits must be signed or electronically verified by provider to show the note was reviewed and the test results were acknowledge - SOLUTION HIPAA medical records problem focused, expanded problem focused, detailed, and comprensive - SOLUTION Levels of E/M services are based on four types of physical examination: . Usual policy of physicans to retain medical records - SOLUTION retention of Records for living patients Use a permanent ink pen to cross out an incorrect entry on patient's record, mark though it with single line, and write the correct infoeramtion, then date an initial the entry. - SOLUTION Error corrections for paper chart note that a section is in error with date and time and enter the correct information with a notation of when and why the physician changed the Chart ALWAYS travels with the _patient Patient goes to operating room - operating room Patient is on the floor - on the floor -For long periods of hospitalization Chart is _thinned_ - infrequently used information is removed Removed information is still stored on patient floor - SOLUTION Where can the chart always be found? Sections of the Patient Medical Chart - SOLUTION Admitting data _Physician orders_ Graphic charts (flow sheets) Nursing notes Laboratory data Diagnostic procedures Operating room procedures History and _Physical_______ Progress notes _Medication Administration Report (MAR) Miscellaneous -Standardized forms forms generally used -Located at the front of chart -Contains biographical data including: Name DOB Marital status Gender Emergency contact Financial status Insurance information Guarantor Provides data to billing department __Date______ and __Time______ of admission Name of admitting physician Admitting diagnosis/problem Admitting service - SOLUTION What information does the Admitting Data contain? Consent Forms Documents risks and benefits of a specific action that takes place during admission Types include: Medical treatment Tests/procedures Investigational treatment/drugs Release of information Photographs, videotapes, film of patient Health Insurance Portability and Accountability Act (HIPAA) forms Even the smallest amount of risks. All types of FORMS are going to be in admitting data. - SOLUTION Besides information, what else must be filed under admitting data? What comes after Admitting data? - SOLUTION Physician Orders What are physician orders and what types are there? - SOLUTION __Directives______ for patient treatment Types of orders Written _Verbal_______ Telephone What follows physician orders? - SOLUTION Graphic Charts. Also known as _flowsheets_______ Standardized forms that simplify data collection and retrieval Quantitative records of _repetitive monitoring activities Arranged to easily visualize __trends______ and _patterns Can be standardized to specific nursing units or patients receiving special therapy - SOLUTION What are graphic charts also known as and what information do the contain? Vital signs Intake and output ADLs Blood glucose Insulin doses Intravenous fluids Blood products Neurologic checks - SOLUTION Name examples what information can be obtained from graphic charts. What is the section of the patient's chart after graphic charts? - SOLUTION Nursing notes. Used to document _observations_______ and patient care _activities_______ Builds on info from _graphic charts_ Can be separate section or integrated in physician's progress notes can be separate or will be part of the progress notes. - SOLUTION What are nursing notes exactly? Physical functioning (are they moving) Behavior/mental status (memory) Clinical signs/symptoms Nursing interventions: PRN medications administered Risk assessments Pain assessments or interventions Documentation of care ANY AS NEEDED MEDICATIONS THAT WERE GIVEN!!!! Patient _education_______ Nursing consults Nursing care plans Nursing admission data _Discharge__ planning - SOLUTION What information can be found in nursing notes? What section of the chart follows nursing notes? - SOLUTION Laboratory Data Lab test results are usually contained in one section Most facilities will have a _computer_______ -based lab system Patient's most recent values will be reported in the computer review this source _first. Lab tests results in the chart typically appear in summary form and are updated daily _Abnormal_ lab values highlighted with * L = low Dated Timed _Signed_______ Handwritten, dictated, or typed Outline or narrative format Documentation of errors Single cross out with _error__ written above Includes person's initials and date - SOLUTION What the characteristics of a properly written Progress Note? Filed in forward or reverse _chronological_ order Pharmacists contribute to progress notes Admission medication history Discharge medication counseling Provision of drug information Recommendations to modify therapeutic regimens Reverse order. The newest day on top. Oldest day on the bottom of stack. - SOLUTION How are the Progress Notes organized? What section is located after Progress Notes - SOLUTION ? Medication Administration Record (MAR) Medication administration not documented on MAR _Physician____ administration - progress notes Medications given during code - code sheet Perioperative orders - anesthesia or _operating___ records - SOLUTION What is listed in MAR section? What section is after the MAR? - SOLUTION Miscellaneous Contains information that is not included in other sections Examples include Ambulance reports Records from outside hospitals _Discharge___ orders Documentation of patient's valuables - SOLUTION What information is found in Miscellaneous? Healthcare providers within the hospital Administrative personnel of facility Patients (have to sign form) Legal Educational Research Audit You should only use the chart if needed. - SOLUTION Who should use the chart? Healthcare_______ professionals Physicians Nurse practitioners Physician assistants Pharmacists Nurses Dieticians Physical therapists Respiratory therapists Administrative_______ personnel Hospital administrators Medical records personnel Ward clerks __Patients______ For outpatient provider For insurance purposes - SOLUTION List the people who fall under these categories to use the chart. __Legal______ use Used as _evidence__ in legal action or suit Why it is important to document ALL interventions correctly Malpractice suits may be filed for various reasons Poor judgment of standard of care Medication or treatment errors Negligence Adverse drug effects _Educational_______ use Students receive valuable instruction from "real life" patient charts Important to remove all patient identifiers and obtain appropriate permission for use _Research_____ use Charts can provide clinical and health statistics research Important to obtain IRB and HIPAA approvals prior to commencement of research - SOLUTION Outside the hospital, who else would need to use the chart? Health Insurance _Portability_ and _Accountability_ Act Created a national standard to protect individuals' medical records and other health information Sets forth requirements for all healthcare professionals concerning protected health information - SOLUTION What does HIPPA stand for and what did it implement? Medical information is only useful when it is properly understood and accurately interpreted Use most recent data available Use similar types of information to help assess patient Know where new data can be found Assess the whole picture before arriving at a conclusion - SOLUTION What information and steps should you use when assesing a patient? eyelid - SOLUTION blephar/o hearing - SOLUTION -cusis the iris - SOLUTION irid/o irit/o ir/I ir/o the lens of the eye - SOLUTION phac/o phak/o retina - SOLUTION retin/o- lacrimal sac - SOLUTION dacryocyst/o the lacrimal apparatus - SOLUTION lacrim/o eyes - SOLUTION opt/I opt/o optic/o picture or record - SOLUTION -gram visual examination - SOLUTION -scopy bleeding - SOLUTION -rrhagia before birth - SOLUTION Prenatal the time and events surrounding birth - SOLUTION perinatal the time and events after birth - SOLUTION postnatal away from, negative, absent - SOLUTION ab- toward, to, in the direction of - SOLUTION ad- right - SOLUTION dextr/o left - SOLUTION sinistr/o outside, out of, away from - SOLUTION ex- in, into, not, without - SOLUTION in- large, abnormal size, long (ie: macroscopic) - SOLUTION macro- small (ie: microscopic) - SOLUTION micro- large, great - SOLUTION megal/o- mega before - SOLUTION pre- after - SOLUTION post- scanty, few - SOLUTION olig/o between, among - SOLUTION inter- less, below - SOLUTION sub- above, excessive - SOLUTION super- above, excessive - SOLUTION supra- within, inside - SOLUTION intra- good, normal, well, easy - SOLUTION eu- the study of - SOLUTION -ology stone - SOLUTION lith- fungus - SOLUTION myc/o bone marrow, spinal cord - SOLUTION myel/o muscle - SOLUTION my/o specialist - SOLUTION -ologist renal pelvis (part of the kidney) - SOLUTION pyel/o pus - SOLUTION py/o fever, fire - SOLUTION pyr/o belly side of the body (ie: ventral) - SOLUTION ventr- back of the body (ie: dorsal) - SOLUTION dors- front, before (ie: anterior) - SOLUTION anter/o- situated in the back (ie: posterior) - SOLUTION poster/o- head - SOLUTION cephal/o- tail, lower part of the body - SOLUTION caud/o- cartilage (ie: hypochondriac...1of9 regions of abdominopelvic) - SOLUTION chondr/o- gland - SOLUTION aden/o- fat - SOLUTION adip/o cell - SOLUTION cyt/o -cyte in, within, inside - SOLUTION -end endo- out of, outside, away from - SOLUTION exo- tissue - SOLUTION hist/o- histi/o- disease, suffering, feeling, emotion - SOLUTION path/o disease, suffering, feeling, emotion - SOLUTION -pathy development, growth, formation - SOLUTION plas/I plas/o development, growth, formation - SOLUTION -plasia control, maintenance of a constant level - SOLUTION -statsis -static stomach - SOLUTION gastr/o- nose - SOLUTION rhin/o liver (ie: hepatitis) - SOLUTION hepat/o- gland - SOLUTION aden/o heart - SOLUTION cardi/o (2nd one) tumor, neoplasm - SOLUTION -oma kidney - SOLUTION nephr/o blood (ie: hematology) - SOLUTION hemat/o stretch out - SOLUTION tens- breastbone (ie: sternum) - SOLUTION stern/o- collar bone - SOLUTION cleid/o- flesh - SOLUTION sarc/o deficiency - SOLUTION -penia without - SOLUTION a- violent action - SOLUTION clon- slow - SOLUTION brady- weakness, lack of strength - SOLUTION -asthenia on, upon - SOLUTION epi- condyle (skeletal system) - SOLUTION condyl- partial or incomplete paralysis - SOLUTION -paresis half - SOLUTION hemi- four - SOLUTION quadr/i electricity - SOLUTION electr/o heart - SOLUTION card/o- cardi/o- blood vessel (ie: angioplasty, vascular) - SOLUTION angi/o- vas/o- capillary - SOLUTION capill/o vein - SOLUTION phleb/o- ven/o- ears - SOLUTION acous/o acoust/o audi/o audit/o ot/o artery - SOLUTION arteri/o blood - SOLUTION hem/o- hemat/o- blood or lymph vessel - SOLUTION angi/o- aorta - SOLUTION aort/o plaque, fatty substance - SOLUTION ather/o a mixture, blending - SOLUTION -crasia blood, blood condition - SOLUTION -emia fast, rapid - SOLUTION tachy- clot - SOLUTION thromb/o blood vessels (ie: vascular) - SOLUTION vascul- protein - SOLUTION -globin hold back - SOLUTION isch- crown - SOLUTION coron- something inserted - SOLUTION embol- color - SOLUTION chromat- bacteria - SOLUTION bacter- fat (ie: mono lipids) - SOLUTION lipid- without, less than - SOLUTION an- growth - SOLUTION -plast destroy - SOLUTION -lytic immature - SOLUTION -blast pertaining to - SOLUTION -tic -ic -ac -eal -ior -al -ical -ory -an -ial -ous -ar - ary -ine valve - SOLUTION valv/o aneurysm - SOLUTION aneurysm/o abnormal condition - SOLUTION -ago -iasis -osis -esis -ion -ia -ism lymph - SOLUTION lymph/o lymphatic vessels and ducts - SOLUTION lymphangi/o lymph nodes - SOLUTION lymphaden/o tonsils and adenoids - SOLUTION tonsill/o adenoids and tonsils - SOLUTION adenoid/o spleen - SOLUTION splen/o lymphocytes - SOLUTION lymphocyte/o thymus - SOLUTION thym/o against - SOLUTION anti- cancerous - SOLUTION carcin/o immune, protection, safe - SOLUTION immun/o new, strange - SOLUTION neo- new, strange - SOLUTION ne/o tumor - SOLUTION onc/o eat, swallow - SOLUTION phag/o- glomerulus - SOLUTION glomerul/o stone, calculus - SOLUTION lith/o breakdown, separation, setting free, destruction, loosening - SOLUTION - lysis surgical fixation - SOLUTION -pexy to crush - SOLUTION -tripsy urination, urine - SOLUTION -uria cerebrum, brain - SOLUTION cebebr/o, encephal/o spine - SOLUTION myel/o nerves - SOLUTION neur/i-, neur/o- burning, burn - SOLUTION caus/o shaken together, violently agitated - SOLUTION concuss/o sensation, feeling (ie: anesthesia) - SOLUTION -esthesia feeling, nervous sensation, sense of perception - SOLUTION esthet/o- the process of producing a picture or record (ie: sonography) - SOLUTION -graphy membranes, meninges - SOLUTION mening/o abnormal fear - SOLUTION -phobia mind (ie:psychiatric) - SOLUTION psych/o- root, nerve root - SOLUTION radicul/o having an affinity for - SOLUTION tropic one who or one which - SOLUTION er condition, state, or theory - SOLUTION ism condition - SOLUTION tion specialist - SOLUTION ist one who - SOLUTION er quality - SOLUTION ity possessing, having, full of - SOLUTION ous ability - SOLUTION able ability - SOLUTION ible enlarged - SOLUTION megaly process or condition (noun) - SOLUTION y (noun) study of - SOLUTION logy (noun) one who studies - SOLUTION logist inflammation - SOLUTION itis instrument used to cut slices - SOLUTION tome incision - SOLUTION tomy excision - SOLUTION ectomy to make a surgical artificial opening - SOLUTION ostomy an instrument used to record data - SOLUTION graph picture or record - SOLUTION gram pain - SOLUTION algia pain - SOLUTION dynia disease - SOLUTION pathy disease, condition, status, process - SOLUTION osis (changes -osis from a noun to an adjective) - SOLUTION tic cell - SOLUTION cyte embryonic or immature cell - SOLUTION blast blood - SOLUTION emia an instrument used to measure or count something - SOLUTION meter decrease in or not enough - SOLUTION penia process of measuring or counting something - SOLUTION metry blood - SOLUTION em an increase in numbers (when used with blood cells) - SOLUTION osis nourishment - SOLUTION trophy tumor - SOLUTION oma in on place (staying) - SOLUTION stasis like or resembling - SOLUTION oid abnormal growth (adjective) - SOLUTION plast/ic development - SOLUTION genesis abnormal protrusion or swelling - SOLUTION cele instrument used to make thin slices in bone - SOLUTION osetotome process and procedure of using an instrument to make thin slices - SOLUTION -tomy process and procedure of using a dermatome(instrument) to make thin slices in the skin - SOLUTION dermatomy process and procedure of using a osteotome(instrument) to make thin slices in bone - SOLUTION osteotomy instrument that records visually - SOLUTION -graph instrument that visually records a x-ray - SOLUTION radiograph the product of using a recording instrument. the recording or image produced. - SOLUTION -gram the x-ray recoding or image produced - SOLUTION radiogram process or procedure of using an instrument to record visually - SOLUTION -graphy process of producing images visually using an x-ray - SOLUTION radiography a measuring instrument - SOLUTION -ometer a instrument used to measure temperature - SOLUTION thermometer a instrument used to measure lung capacity - SOLUTION spirometer process or procedure of using a measuring instrument - SOLUTION - ometery process or procedure of using a measuring instrument to measure the pelvis - SOLUTION pelvimetry process or procedure of using a measuring instrument to measure temperature - SOLUTION thermometry process or procedure of using a measuring instrument to measure lung capacity - SOLUTION spirometry instrument used for examining(usually visually or sound) - SOLUTION - oscope instrument used for visually examining the eye - SOLUTION ophthalmoscope instrument used for visually examining the bladder - SOLUTION cystoscope instrument used for examining the chest by listening - SOLUTION stethoscope instrument used for listening to fetal heart sounds - SOLUTION fetoscope process and procedure of using an instrument to examine - SOLUTION - oscopy process and procedure of using an instrument to examine the eye - SOLUTION ophthalmoscopy process and procedure of using an instrument to examine the bladder - SOLUTION cystoscopy process and procedure of using an instrument to examine by listening to fetal heart sounds - SOLUTION fetoscopy binding together - SOLUTION -desis binding together of a vessel - SOLUTION vasodesis to cut, pertaining to - SOLUTION -cision pertaining to cut into - SOLUTION incision pertaining to cut out - SOLUTION excision process or procedure to excise or to surgically remove - SOLUTION - ectomy process or procedure to surgically remove the tonsil - SOLUTION tonsillectomy process or procedure to surgically remove the appendix - SOLUTION appendectomy incision into - SOLUTION -otomy incision into the abdomen - SOLUTION laparotomy incision into the colon - SOLUTION colotomy incision into the the trachea - SOLUTION tracheotomy process or pocedure of fixing and suturing - SOLUTION -opexy process or procedure of fixing and suturing the fallopian tubes - SOLUTION salpingopexy process or procedure of fixing and suturing the uterus into place - SOLUTION hysteropexy process or procedure of fixing and suturing the lips into place - SOLUTION cheilopexy process or procedure of reconstructive surgery - SOLUTION -oplasty process or procedure of nose reconstruction surgery - SOLUTION rhinoplasty process or procedure of joint reconstruction surgery - SOLUTION arthroplasty process or procedure of vessel reconstruction - SOLUTION angioplasty symptoms united in a pattern - SOLUTION syndrome preceeding a pattern/ early warning before outbreak - SOLUTION prodromal related to knowledge - SOLUTION -gnosis thorough - SOLUTION -dia thorough knowledge - SOLUTION diagnosis before knowledge/ a prediction of a likely outcome - SOLUTION prognosis soften - SOLUTION malacia softening of the bone - SOLUTION osteomalacia process or procedure of enlargement - SOLUTION megaly process or procedure of enlargement of the heart - SOLUTION cardiomegaly process or procedure of enlargement of the bladder - SOLUTION cystomegaly destroy or separate - SOLUTION olysis destroy or separate the blood - SOLUTION hemolysis resembles or similar to - SOLUTION -oid fat - SOLUTION -lip mucous - SOLUTION -muc shield - SOLUTION -thyr dagger - SOLUTION -xyph resembles or similar to fat - SOLUTION lipoid resembles or similar to mucous - SOLUTION mucoid resembles or similar to a shield - SOLUTION thyroid resembles or similar to a dagger - SOLUTION xyphoid urine or urination, related to - SOLUTION -uria related to bacteria in the urine - SOLUTION pyuria related to blood in the urine - SOLUTION hematuria process or procedure of development from usage - SOLUTION -trophy no muscular process of development - SOLUTION atrophy excessive process of muscular development from usage - SOLUTION hypertrophy breathing - SOLUTION -pnea difficult,painful - SOLUTION -dys no, not, any or without - SOLUTION -a,ar,an without breathing/no breathing - SOLUTION apnea difficult or painful breathing - SOLUTION dyspnea related to paralysis - SOLUTION -plegia half or one side - SOLUTION -hemi related to one-sided paralysis - SOLUTION hemiplegia four - SOLUTION -quad related to paralysis from the neck down - SOLUTION quadriplegia related to voice due to laryngeal issues - SOLUTION -phonia related to no voice due to larygneal issues - SOLUTION aphonia related to cellular growth or development - SOLUTION -plasia related to no cellular growth or development - SOLUTION aplasia low - SOLUTION -hypo related to excessive cellular growth or development - SOLUTION hyperplasia excessive - SOLUTION -hyper related to low cellular growth or development - SOLUTION hypoplasia related to speech - SOLUTION phasia related to no speech/without speech - SOLUTION aphasia related to eating or swallowing - SOLUTION -phagia related to no eating or swallowing - SOLUTION aphagia remarkable weakness - SOLUTION -paresis remarkable weakness on one side - SOLUTION hemiparesis condition of something - SOLUTION -osis skin condition - SOLUTION dermatosis nerve condition - SOLUTION neurosis unusual reduction - SOLUTION -openia white - SOLUTION -leuk beside, beyond, near, abnormal - SOLUTION para toward - SOLUTION ad in front of - SOLUTION pro through or complete - SOLUTION dia bad, painful, difficult - SOLUTION dys well or easy - SOLUTION eu outer-outside - SOLUTION ecto inner-inside - SOLUTION endo middle - SOLUTION meso backward-behind - SOLUTION retro near - SOLUTION para outside - SOLUTION exo first - SOLUTION proto water or fluid - SOLUTION hydro sweat - SOLUTION hidro half - SOLUTION hemi half - SOLUTION semi one - SOLUTION mono one - SOLUTION uni first - SOLUTION prot first - SOLUTION prim two - SOLUTION di(plo) two - SOLUTION bi three - SOLUTION tri four - SOLUTION tetra four - SOLUTION quadr five - SOLUTION penta five - SOLUTION quint six - SOLUTION hexa six - SOLUTION sex/ta seven - SOLUTION hepta seven - SOLUTION sept/a eight - SOLUTION octa eight - SOLUTION oct nine - SOLUTION enne(a) nine - SOLUTION non(i) ten, tenth - SOLUTION deca ten, tenth - SOLUTION dec(i) one hundred, one hundredth - SOLUTION hecto one hundred, one hundredth - SOLUTION cent(i) one thousand, one thousandth - SOLUTION kilo one thousand, one thousandth - SOLUTION mill(i) many or more than one - SOLUTION multi none - SOLUTION nulli first - SOLUTION primi away from - SOLUTION ab down from or from--resulting in less than - SOLUTION de out from - SOLUTION ex through, complete - SOLUTION dia through - SOLUTION per around - SOLUTION peri around - SOLUTION circum same - SOLUTION homo opposite - SOLUTION hetero together or joined - SOLUTION syn together or joined - SOLUTION sym above or beyond - SOLUTION super above or beyond - SOLUTION supra without or lack of - SOLUTION a without or lack of - SOLUTION an aseptic hand washing - SOLUTION most important procedure for medical assistant. wash regularly, including beginning of the day, before and after lunch, before using gloves, handling specimens or waste, handling clean and sterile supplies; before and after seeing each patient, after blowing your nose and coughing, after breaks, and before leaving for the day. The life span of a record as expressed in the five phases of creation, distribution, use, maintenance, and final disposition. - SOLUTION records life cycle id sheet; history and physical exam records; consent forms; physician's progress records; physician order sheets; lab reports; consultation reports; discharge summary - SOLUTION parts of hospital medical record explanation of benefits - SOLUTION eob document sent by the insurance company to the provider and insured explaining what was covered for each service. - SOLUTION explanation of benefits expressed consent - SOLUTION Must be obtained from a conscious, competent adult before treatment. Parent must be legal age and rational. Patient must be informed. implied consent - SOLUTION Assumption on behalf of a person unable to give consent that he or she would have done so. A written agreement to participate in a study made by an adult who has been informed of all the risks that participation may entail. - SOLUTION informed consent a development by the American Medical Association that guarantees a patient the right to receive courteous, considerate,respectful treatment in a clean/safe environment; appropriate healthcare; information about his/her health treatment plan in a way that he or she understands; a continuity of care; confidentiality privacy;participation in planning care and treatment;refusal of care; use of grievance mechanisms; treatment without discrimination;an itemized bill and explanation of all charges; and review of the medical record and/or copy at reasonable fee. - SOLUTION patient bill of rights procedures for handling or working with that substance· in a safe manner· , and includes information such as physical data ( melting point·, boiling point·, flash· point·, etc.), toxicity , health effects , first· aid·, reactivity·, storage· , disposal· , protective equipment· , and spill-handling procedures . MSDS formats can vary· from source· to source· within a country· depending on national· requirements . - SOLUTION material data safety sheet material data safety sheet - SOLUTION msds preferred provider - SOLUTION Usually includes an annual deductible and coverage begins after it has been fully paid . Coverage is sometimes available prior to meeting that deductible for services such as doctor· visits (which require· a low· Co-pay) . Includes a network of physicians , hospitals , and specialists that have· agreed to offer· services at a reduced fee· . No referral· from a primary care· physician· is required to see· a specialist· . Allows the flexibility to visit· providers outside the network for a slightly higher fee· and a separate deductible . Often requires a claim· to be· filed before your benefit· reimbursement can be· made . Co-pays and monthly premiums are typically higher than that of an HMO plan· (see below) due to the flexibility . preferred provider organization - SOLUTION ppo hmo - SOLUTION usually have· co-pays and monthly premiums that are lower than those of a PPO plan· . There is a network of physicians , hospitals , and other specialists offering services at a reduced fee· . The patient· chooses a primary care· physician· who helps coordinate the patient's care· . This physician· must provide· a referral· for the patient· to see· an in-network specialist· . No coverage for providers outside of the network of physicians , hospitals , and specialists , meaning you're charged the full· fee· if you choose· to visit· them , with the exception· of medical emergencies . Few or no claims to be· filed , since the insurance· company· pays the provider· directly health maintenance organization - SOLUTION hmo , A tax-advantaged personal savings account, set up to be used exclusively for medical expenses; must be paired with a high-deductible health insurance policy - SOLUTION Health savings account health savings account - SOLUTION hsa outdated used to collect information about diseases and injuries and to classify diagnoses and procedures - SOLUTION . icd 9 Bones , axial skeleton· , appendicular skeleton· , and joints - SOLUTION skeletal Muscles and tendons - SOLUTION Muscular Skin , hair· , nails , and glands in skin· - SOLUTION Integumentary Eyes , ears , nose· , skin· receptors , and mouth· - SOLUTION Sensory Heart , blood· vessels , and blood· - SOLUTION Cardiovascular Tonsils , spleen· , thymus , lymph nodes , lymphatic vessels , and lymph fluid - SOLUTION Lymphatic Nose, pharynx, larynx, trachea, bronchi, and lungs - SOLUTION Respiratory Mouth , esophagus· , stomach , small· and large· intestines , pancreas , liver , and gallbladder - SOLUTION Gastrointestinal Hormones, pituitary gland, thyroid, adrenal glands, pancreas, and gonads - SOLUTION Endocrine Brain , spinal cord· , ganglia , nerves , and sensory· organs - SOLUTION Nervous Kidneys, ureters, bladder, and urethra - SOLUTION Urinary Nipple - SOLUTION Papill/o Pelvis - SOLUTION Pelv/o Penis - SOLUTION Phall/o Hair - SOLUTION Pil/o Foot - SOLUTION Pod/o Nose - SOLUTION Rhin/o Body - SOLUTION Somat/o Chest - SOLUTION Steth/o Mouth - SOLUTION Stomat/o Ankle - SOLUTION Tal/o Foot - SOLUTION Tars/o Chest/thorax - SOLUTION Thorac/o Neck or necklike - SOLUTION Trachel/o Hair or hairlike - SOLUTION Trich/o Front of body - SOLUTION Ventr/i, ventr/o Abdomen - SOLUTION Abdomin/o Gland - SOLUTION Aden/o Adrenal gland - SOLUTION Adren/o Air sac - SOLUTION Alveoli/o Vessel - SOLUTION Angi/o Artery - SOLUTION Arteri/o Arteriole - SOLUTION Arteriol/o Joint - SOLUTION Athr/o Atrium - SOLUTION Atri/o Hearing - SOLUTION Audi/o Glans penis - SOLUTION Balan/o Life - SOLUTION Bio- Bronchus - SOLUTION Bronch/i, bronch/o Bronchiole - SOLUTION Bronchiol/o Cancer - SOLUTION Carcin/o Heart - SOLUTION Cardi/o Cell - SOLUTION Cellul/o Cerebellum - SOLUTION Cerebell/o Cerebrum - SOLUTION Cerebr/i, cerebr/o Bile - SOLUTION Chol/e Gallbladder - SOLUTION Cholecyst/o Common bile duct - SOLUTION Choledoch/o Cartilage - SOLUTION Chondr/i, chondr/o Color - SOLUTION Chrom/o Colon - SOLUTION Col/o Vagina - SOLUTION Colp/o Rib - SOLUTION Cost/o Cold - SOLUTION Cry/o Hidden - SOLUTION Crypt/o Skin - SOLUTION Cutane/o Blue - SOLUTION Cyan/o Bladder or cyst - SOLUTION Cysti, cyst/o Cell - SOLUTION Cyt/o Double, twice - SOLUTION Dipl/o Duodenum - SOLUTION Duoden/o Brain - SOLUTION Encephal/o Intestine - SOLUTION Enter/o Vulva - SOLUTION Episi/o Red - SOLUTION Erythr/o Esophagus - SOLUTION Esophag/o Fibers - SOLUTION Fibr/o Milk - SOLUTION Galact/o Stomach - SOLUTION Gastr/o Sugar - SOLUTION Glyc/o Female - SOLUTION Gynec/o Lungs - SOLUTION Pneum/a, pneum/o Lungs - SOLUTION Pneum/ato, pneum/ono Gray matter of nervous system - SOLUTION Poli/o Rectum, anus - SOLUTION Proct/o Lungs - SOLUTION Pulmon/o Pus - SOLUTION Py/o Pelvis of kidney - SOLUTION Pyel/o Rectum - SOLUTION Rect/o Kidney - SOLUTION Ren/i, ren/o Sacrum - SOLUTION Sacr/o Fallopian tube - SOLUTION Salping/o Flesh - SOLUTION Sarc/o Scapula - SOLUTION Scapul/o Infection - SOLUTION Sept/o Spleen - SOLUTION Splen/o Vertebra - SOLUTION Spondyl/o Sternum - SOLUTION Stern/o Tendon - SOLUTION Tend/o, ten/o Testis - SOLUTION Testicul/o Heat - SOLUTION Therm/o Chest - SOLUTION Thorac/o Thymus - SOLUTION Thym/o Thyroid gland - SOLUTION Thyr/o Thyroid gland - SOLUTION Thyroid/o Tonsils - SOLUTION Tonsill/o Trachea - SOLUTION Trache/o Eardrum - SOLUTION Tympan/o Urine - SOLUTION Ur/e, ur/ea, ur/eo, urin/o, ur/o Ureter - SOLUTION Ureter/o Urethra - SOLUTION Urethr/o Vas deferens - SOLUTION Vas/o Vein - SOLUTION Vas/o, ven/o Bladder - SOLUTION Vesic/o Viscera (internal organs) - SOLUTION Viscer/o Red, redness - SOLUTION Xanth/o Dry - SOLUTION Xer/o Lack of, without, not - SOLUTION A-, an- Before, in front of, or forward \ - SOLUTION Ante- Opposing or against - SOLUTION Anti- Double, two, twice, both - SOLUTION Bi- Together or with - SOLUTION Co-, con-, com- Down, or from - SOLUTION De- Twice or two - SOLUTION Di- Beyond, outside of, or outward - SOLUTION Extra-, extro- Half, half of - SOLUTION Hemi-, semi- Above, excessive, beyond - SOLUTION Hyper- Below, beneath, deficient - SOLUTION Hyp-, hypo- Into, or within - SOLUTION Intro- Large - SOLUTION Macro- Tiny, small - SOLUTION Micro-, micr- After, or following, behind - SOLUTION Post- In front of, before, preceding - SOLUTION Pre-, pro- Behind, backward - SOLUTION Retro- Half - SOLUTION Semi- Through or across - SOLUTION Trans- Three - SOLUTION Tri- Excessive, beyond - SOLUTION Ultra- Related to, or pertaining to - SOLUTION -ac, -ic, -al, -ous, -tic Subject to, use - SOLUTION -ate, -ize Person, agent - SOLUTION -ent, -er, -ist Social Space - SOLUTION 4-12 feet personal space - SOLUTION intimate touching to 1.5 ft personal space - SOLUTION 1.5 to 4 ft public space - SOLUTION 12 to 15 ft sign release form - SOLUTION To release info patient must Muscle site in the upper extremity that is used as an injection site is - SOLUTION deltoid big part of brain - SOLUTION Cerebrum mouth - SOLUTION Gustatory receptors in PCP - SOLUTION Managed care gatekeeper Communication cycle - SOLUTION message, receiver, feedback, sender insurance claim form - SOLUTION If the physician accepts assignment of benefits should be on top - SOLUTION Personal mail goes on below return address - SOLUTION Confidential on mail goes future events arranged in chronological order - SOLUTION Tickler file direction to look for additional codes - SOLUTION See also comparison of ledger card totals and account receivable bonus - SOLUTION Trial balance checkbook - SOLUTION Bank statement reconciled with w-4 form - SOLUTION New employee must complete in daily log - SOLUTION In double entry booking original entry is put external causes - SOLUTION E codes fee for service - SOLUTION Ppo uses regular monthly premium - SOLUTION Medicare part B CMS developed by - SOLUTION health care financing administration POMR main example - SOLUTION SOAP Credit balance on account - SOLUTION occurs when patient pays in advance Aural temp is in - SOLUTION ear how are test results arranged? - SOLUTION Placed most recent on top to oldest on bottom demographic and billing information; placed in front of chart; may include copy of insurance card and photo identification - SOLUTION Patient registration record parts of medical chart - SOLUTION Chief complaint; past medical history; family history; present illness; social history; occupational history; physical examination; test history; consultations; past medical records; correspondence; progress notes; medical and prescription record; immunization record; consent forms; release of information form; patient registration record expanded CC - SOLUTION Present illness demographic and billing information; placed in front of chart; may include copy insurance and photo ID - SOLUTION Patient registration record observations and data are categorized according to their source; forms are filed in reverse chronological order (most recent on top); information filed in separate sections - SOLUTION Source oriented medical record data are organized according to patient's disease or condition; divided into four parts (database, problem list, plan, progress notes) - SOLUTION Problem oriented medical record part of POMR; includes CC, PI, PE, and lab results; each condition gets own page - SOLUTION Database numbered and titled list of every patient complaint; part of POMR - SOLUTION Problem list diagnostic and treatment decisions for the condition; each plan titled and numbered - SOLUTION Plan structured notes that correspond to each problem number; uses the acronyms - SOLUTION Progress notes SLIDE acronym - SOLUTION Errors in charting six cs of charting - SOLUTION Current, complete, concise correct, confidential, clean process of moving file from active to inactive - SOLUTION Purging transforming written or dictated medical info into a permanent doc - SOLUTION Medical transcription Filing Process - SOLUTION Condition, inspect and release, index and code, sort, store check for damage, remove pins, staple grouped docs, date your work - SOLUTION Condition docs can't be filed until the responsible parties have seen the doc and taken action, release mark must be noted - SOLUTION Inspect and release determine where documents should be filed, identify the caption, include date and patient name - SOLUTION Index and code arrange the docs - SOLUTION Sort most common; all transactions recorded at one time; uses pegboard, day sheet, ledger card, charge slip/receipt - SOLUTION Pegboard (write it once) system presented at each visit; payment made each time in small amounts - SOLUTION Superbill each transaction recorded in a way that keeps a balance of accounting equation - SOLUTION Double entry system accounting software package - SOLUTION Total practice management system to remove petty cash - SOLUTION Voucher A form prepared by a business (buyer) and sent to another business (seller/supplier) to order items or services. - SOLUTION Purchase order fee most frequently charged - SOLUTION Usual fee range of usual fees charged for the particular service by practitioners of similar training - SOLUTION Customary fee fee assigned to an unusual service; meets the criteria of ucr - SOLUTION Reasonable fee increase or decrease to patient account not due to charges incurred or payments received - SOLUTION Adjustment provider treats another health care professional for free - SOLUTION Professional Courtesy patient's signature requests the insurance company to send insurance proceeds directly to the provider - SOLUTION Assignment of benefits form records of debit and credit activity of a patient in the practice - SOLUTION Ledger cards analysis of accounts receivable indicating 30, 60, 90 and 120 days delinquency - SOLUTION Aging accounts sets minimum wage; requires employers to pay 1.5 if work over 40 hours - SOLUTION Fair Labor Standards Act prohibits discrimination based on race, color, religion, or gender - SOLUTION Title 7 ,civil rights act 1964 prohibits unfair practices in employment regarding people older than 40 years of age - SOLUTION Age Discrimination in Employment Act Social security and medicare tax; employers are required to collect these taxes from wages, must submit amount withheld, taxes deducted from pay every day, employer must match them dollar to dollar - SOLUTION FICA withheld tax to support unemployment insurance - SOLUTION FUTA Federal Tax Id Number - SOLUTION Form SS-4 social security number application form - SOLUTION Form SS-5 Wages and Tax Statement - SOLUTION Form W2 transmittal of income and tax statement - SOLUTION Form W3 Employee's withholding allowance certificate - SOLUTION Form W4 employee's annual federal unemployment tax return - SOLUTION Form 940 employee's quarterly federal tax return - SOLUTION Form 944 Federal Tax Deposit Coupon Book - SOLUTION Form 8109 IRS form to report income other than wages - SOLUTION Form 1099 translates descriptions of diseases, illnesses, injuries, procedures into numeric codes - SOLUTION Coding volume 1 tabular list of 3 to 5 digit diseases volume 2 alphabetical list of diseases, side effects, and e codes; third volume list of procedures - SOLUTION ICD-9 CM International Classification of Diseases Ninth Edition clinical modification Health care financing administration; used to report Medicare services - SOLUTION HCFA assigned unit value given to commonly performed medical procedure - SOLUTION Relative Value Scale fee schedule for medicare for services based on level of resources needed - SOLUTION Resource based relative value scale not elsewhere classifiable - SOLUTION NEC not otherwise specified - SOLUTION NOS 5-7 digits - SOLUTION ICD 10 CM and PCS current procedural terminology; 5 digit code; 6 subsections - SOLUTION CPT protection against financial loss by unplanned health related events - SOLUTION Health insurance organization that provides a comprehensive range of services for prepaid fee - SOLUTION HMO agreement between managed care organization and physician to provide services to employee subscribers at a discount - SOLUTION Preferred provider organization members must receive services within the network only - SOLUTION EPO The part of the Medicare program that pays for hospitalization, care in a skilled nursing facility, home health care, and hospice care. - SOLUTION Medicare Part A -Pays for hospital outpatient physician and other professional services including OT services provided by independent practitioner - SOLUTION Medicare Part B Autoclave is normally run - SOLUTION 250 F; 20lb pressure for 15 mins measurements that indicate a patient's general state of health and homeostasis - SOLUTION Vital signs Normal breathing - SOLUTION Eupnea Difficult breathing - SOLUTION Dyspnea Absence of breathing - SOLUTION Apnea Difficulty breathing when supine. - SOLUTION Orthopnea Deep breathing - SOLUTION Hyperpnea RAPID BREATHING - SOLUTION Tachypnea ABNORMAL CRACKLING SOUND WHICH OCCURS DURING BREATHING - SOLUTION Rales ABNORMAL SOUNDS HEARD WHEN THE AIRWAY IS OBSTRUCTED, A WHEEZE - SOLUTION Rhonchi pattern of breathing characterized by a gradual increase of depth and sometimes rate to a maximum level, followed by a decrease, resulting in apnea - SOLUTION Cheyne-stokes respiration normal breaths/minute - SOLUTION 16-20 breathing pattern - SOLUTION Rhythm amount of air being inhaled - SOLUTION Depth measure hemoglobin saturation; normal range 95 to 99 percent; SpO2 - SOLUTION Pulse Oximetry instrument to measure blood pressure - SOLUTION Sphygmomanometer: unpleasant sensory and emotional experience - SOLUTION Pain :COLDER pain acronym - SOLUTION Character of the pain; onset of the pain; location of the pain; duration of the pain; what exacerbates the pain; relieves the pain deals with the measurement of size, weight, and proportion of human body - SOLUTION Anthropometric measurement standing; arms at sides musculoskeltal and nervous system exam - SOLUTION Erect patient sits upright with legs dangling over edge; drape sheet across lap; examine head, chest, heart, upper part of part - SOLUTION Sitting patient lies flat on the back with arms at the sides; used to examine chest area drape sheet from under arms - SOLUTION Supine Lying on back, knees bent - SOLUTION Dorsal Recumbent For transvaginal examination, the patient must be in what position? - SOLUTION Lithotomy examination position in which the client is lying on his or her left side with right knee flexed. - SOLUTION Sims' Face down - SOLUTION Prone PATIENT REST ON KNEES AND CHEST. BUTTOCKS ARE IN THE AIR, ALSO CALLED "GENUPECTORAL". USED FOR RECTAL AND SIGMOID EXAMS - SOLUTION Knee Chest PATIENT IS PRONE WITH HEAD AND LEGS LOWERED AND THE BUTTOCKS ELEVATED - SOLUTION Proctologic A semi-sitting position; the head of the bed is raised between 45 and 60 degrees - SOLUTION Fowler's Head of bed raised approximately 30 degrees; inclination less than Fowler's position; foot of bed may also be raised at knee diapphragmatic breathing - SOLUTION Semi-Fowler's An examination or operative position wherein the patient is lying face up and on an incline with the head tilted downward and the table angulated beneath the knees - SOLUTION Trendelenburg process of touching and feeling - SOLUTION Palpitation process of tapping or striking body - SOLUTION Percussion forceful passive movement of a joint to determine range of motion - SOLUTION Manipulation process of listening to the body using stethoscope - SOLUTION Auscultation process of measurement - SOLUTION Mensuration illuminate internal eye - SOLUTION Ophthalmoscope illuminate external and internal ear - SOLUTION Otoscope illuminate the mouth, throat, nose for visual examination - SOLUTION Pocket flashlight used to test patient's hearing - SOLUTION Tuning Fork sequence of events at apt - SOLUTION Patient health history; vital signs; physical examine; specimen collection diagnostic test; discussion with provider A test in which a substance is applied topically to the skin on a small piece of blotting paper or wet cloth - SOLUTION Patch test Allergens are applied to a scratch on the skin - SOLUTION Scratch test Surgery using extreme cold to destroy cells - SOLUTION Cryosurgery A display and recording of the electrical activity of skeletal muscle is called an... - SOLUTION Emg used to reduce pain - SOLUTION Analgesics Among the following compounds that serve as coenzymes in metabolism, which is considered a vitamin for human beings? - SOLUTION Biotin 30. Which mineral should be increased during pregnancy - SOLUTION Folate Antihyperlipidemic: inhibits VLDL synthesis and release of fatty acids from adipose tissue. Lowers LDL cholesterol and triglycerides and raises HDL cholesterol. Tox: flushing, pruritus, liver dysfunction, increased risk of myopathy when combined with statins. - SOLUTION Niacin CoEnzyme A; plays a large role in the synthesis of vitamins A & D, cholesterol, steroids, FAs & AAs - SOLUTION Pantothenic acid Ascorbic Acid An important substance needed for proper repair of the skin and tissues; promotes the production of collagen in the skins dermal tissues; aids in and promotes the skins healing process. - SOLUTION Vitamin C A fat soluble vitamin that prevent rickets. Produced in the skin from exposure to sunlight. Found in fatty fish, eggs and meat - SOLUTION Vitamin D Antioxidant - SOLUTION Vitamin E The vitamin produced by the normal flora of the colon in amounts sufficient to meet a person's daily need is.... - SOLUTION Vitamin K begin with a few hypoallergenic foods; if no allergy occurs introduce new food group every 10 days - SOLUTION Rowe elimination diet Activities aimed at improving health and preventing disease by enabling people to increase control over and improve their health - SOLUTION Health promotion temperature pulse respiration - SOLUTION TPR The use of heat, cold, and electrical stimulation to produce an increase or descries in blood flow - SOLUTION Therapeutic modalities heat therapy - SOLUTION Thermotherapy cold therapy - SOLUTION Cryotherapy water therapy - SOLUTION Hydrotherapy patients who require permanent walking assistance - SOLUTION Lofstand crutches A radiological technique that provides real-time images of an anatomical region. - SOLUTION Fluoroscopy Study of Drugs - SOLUTION Pharmacology Provides info on uses, precautions, indications, and doses for various drugs; section 1 manufacturer index; section 2 product name index; section 3 product category index; section 4 generic and chemical name index; section 5 production identification; section 6 production information - SOLUTION Physician's Desk Reference folded sheet of paper within the drug container or box - SOLUTION Product insert mix of oil and water - SOLUTION Emulsion drug dissolved in alcohol - SOLUTION Tincture drug dissolved in a mixture of water, alcohol, and sugar - SOLUTION Elixir drug mixed with soap, oil, or water - SOLUTION Liniment Adult Dose X (Age ÷ (Age+12)) = Child's Dose - SOLUTION Youngs rule a method of determining a pediatric drug dose for a child younger than 1 year of age, based on the child's age and the usual adult dose (assumes that an adult dose would be appropriate for a 12.5-year-old child) - SOLUTION Fried's rule (Weight in lbs./150)x Adult Dose - SOLUTION Clark's Rule Inflammatory phase Proliferation phase Maturation phase - SOLUTION 3 steps in wound healing a device used to measure radiation exposure to personnel - SOLUTION Dosimeter Bone breaks through the skin - SOLUTION compound fracture an uncomplicated fracture in which the broken bones to not pierce the skin - SOLUTION simple fracture a partial fracture of a bone (usually in children) - SOLUTION greenstick fracture Open penetration break - SOLUTION compound complex fracture a thin membrane lining the closed cavities of the body - SOLUTION serous membrane membranes that line the abdominopelvic cavity and cover the organs inside - SOLUTION peritoneal membrane sanitize, disinfect, sterilize - SOLUTION Steps to clean instruments is the process of removing organic matter from an article through cleaning. - SOLUTION Sanitization free from all microorganisms - SOLUTION sterile free from contamination caused by harmful bacteria, viruses, or other microorganisms - SOLUTION aseptic Results of laboratory tests can be used to - SOLUTION Diagnose, manage, assess