Outline for Medical Assisting Review

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					                  Outline for Medical Assisting Review

I.     Administrative Duties in the Medical Office

 A.   Law and Ethics /Medicolegal Guidelines & Requirements
       1.   Licenses and accreditation
               a. Medical practice acts
               b. Renewal of license
               c. Revocation/suspension of license
                    criminal/unprofessional conduct
                    professional/personal incapacity
               d. state requirements
               e. laboratory registration
               f. federal requirements
               g. physician office laboratory (POL)
       2.   Legislation
               a. State compliance
               b. personnel standards, hiring and termination
               c. Medicare/Medicaid reimbursement policies
               d. acts
               e. living wills
               f. anatomical gifts
               g. reportable incidences
               h. public health statutes (e.g., communicable diseases, vital statistics, substance
                   abuse/chemical dependency, abuse against persons)
               i. criminal acts
       3.   Federal compliance
               a. Occupational Safety and Health Act (OSHA)
               b. right to privacy
               c. controlled substances
               d. Medicare/Medicaid regulations
               e. Clinical Laboratory Improvement Act (CLIA ’88)
               f. Americans with Disabilities Act (ADA)
               g. Health Insurance Portability and Accountability Act (HIPAA)
       4.   Documentation/reporting
               a. Sources of information
               b. Drug Enforcement Administration (DEA)
               c. Internal Revenue Service (e.g., personnel forms)
               d. Employment laws
               e. Personal injury occurrences
               f. Workers’ compensation
               g. Medical records
                    patient activity
                    patient care
                    patient confidentiality
                    ownership
               h. Personnel records
               i. evaluation
               j. right to privacy
       5.   Releasing medical information
               a. Consent
                    patient written authorization
               b. state and federal codes
               c. right to privacy
               d. drug and alcohol rehabilitation records
               e. public health and welfare disclosures
               f. rights of emancipated minors

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              g. HIV-related issues
              h. subpoena duces tecum
               i. Rescinding authorization for release
      6.   Physician-patient relationship
              a. Contract
                   legal obligations
                   consequences for noncompliance
      7.   Responsibility and rights
              a. patient
              b. physician
              c. medical assistant
      8.   Guidelines for third-party agreements
      9.   Professional liability
              a. current standard of care
              b. current legal standards
              c. informed consent
     10.   statute of limitations
     11.   negligence
     12.   assumption of risk
     13.   Termination of medical care
              a. establishing policy
              b. elements for withdrawal
              c. patient notification and documentation

B.   Terms for Law and Ethics:

      1.   abandonment: the withdrawal of a physician from the care of a patient without
           reasonable notice of such discharge from the case by the patient.
      2.   AMA Code of Ethics: “A physician shall respect the law”
      3.   assault: an unlawful threat or attempt to do bodily injury to another.
      4.   assumption of risk: the consent to treatment is based on the patient’s full
           understanding of all possible risks of unpreventable results of the treatment
           consented for.
      5.   battery: the deliberate physical attack or force upon a person
      6.   bioethics: study of moral issues, questions or problems arising in the practice of
           medicine in medical research. Example: the use of fetal tissue for transplantation.
      7.   breach of contract: failure to achieve an agreed upon result
      8.   breach of duty: violation or omission of a legal or moral obligation
      9.   civil law: a statute that enforces private right and liabilities, as differentiated from
           criminal law
     10.    consent: permission granted written or verbal, voluntarily and in sound mind
     11.   contract: formal agreement between two or more parties to do or not to do
           something
     12.    contributory negligence: a patient’s failure to act prudently and reasonably or to
           do that which a reasonable person would do under similar circumstances.
     13.    crime: breaking of a law, promise or duty
     14.    defamation: to injure the reputation and name of another person by making false
           statements to a third party
     15.    defendant: the person being sued
     16.    deposition: testimony of a witness under oath, especially a statement given by a
           witness that is read out in court in the witness’s absence.
     17.    emancipated minor: a person who is no longer under the care, custody, or
           supervision of a parent or guardian.
     18.    empathy: the ability to see things from another person’s point of view
     19.    ethics: right and wrong conduct.


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     20.    expert testimony: statement concerning the scientific, technical or professional
           matter by an expert such as a doctor.
     21.    false imprisonment: to hold a person against his/her will. (the reason a patient
           can sign themselves out of the hospital AMA) (AMA-against medical advice)
     22.    felony: a major crime with a stronger sentence than a misdemeanor
     23.    fraud: an instance in which one party deceives or takes unfair advantage of
           another.
     24.    incompetence: lack of physical or mental ability to function properly
     25.    informed consent: the doctor advising patient of procedure guidelines including
           risks and benefits and consent is signed by patient, doctor and at least one witness
     26.    invasion of privacy: a violation of a person’s rights to reveal information such as
           personal medical information, pictures, or personal information without the consent
           of that person.
     27.    judgment: final decision in court in an action or suit
     28.    law: rules of conduct established by a governing body
     29.    malpractice: result of an act of carelessness without an intent to harm.
     30.    medical etiquette: conduct, courtesy, and manners that are customarily used in a
           medical office by medical professionals
     31.    medical grievance: patient complaints investigated by an impartial committee.
     32.    Negligence: the most common type of medical tort liability also termed
           malpractice. Failure to do something that a reasonable person would do under
           ordinary circumstances that ends up causing harm to another person or a person’s
           property.
     33.    peer review: evaluation by a panel of members from same professional level
     34.    plaintiff: the person who institutes a lawsuit
     35.    privileged communication: information given by a patient to a healthcare worker
           that cannot be shared with others not in the position of delivering health care to the
           patient without the patient’s consent
     36.    Statue of limitations: the time limit to file suit.
     37.    subpoena: the write that command s a witness to appear at a trial or other
           proceedings to give testimony
     38.   suspension: temporary interruption with the intention or resumption at a later date
     39.    tort: wrongful act that causes injury to a person or property and for which the law
           allows a claim by the injured party to recover damages (money)
     40.    will: instructions given on disbursement of property after one’s death

C.   Latin Terms
      1.   respondeat superior: responsibility of the actions of the employee rests on the
           employer
      2.   non compos mentis: a person not of sound mind
      3.   res gestae: things done; deeds, the facts and circumstances attendant to the act in
           question
      4.   res ipsa loquitur: presumption of negligence when an accident cannot be explained
           in ordinary experiences
      5.   res judicata: things decided
      6.   qui facit per alium facit per se: he who acts through another acts for himself

D.   Risk Management

      1.   The most common form of exposure incidents in hospital and clinical settings:
           needle-stick
      2.   The type of communication a new employee must learn to be educated on possible
           risks on the jobsite: Hazard Communication Standard


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       3.   After cleaning a needle-stick with soap and Betadine what is the next most important
            step: tell supervisor of incident so an incident report can be filed
       4.   OSHA stands for: Occupational Safety Health Administration
       5.   OSHA regulates: employees and their patients or clients in the workplace
       6.   Universal precautions: approach to all human blood and certain body fluids that
            are considered infectious.
       7.   Standard Precaution: the use of Universal Precautions when dealing with patients.
            This is the guideline for hospital and clinical care for patients.

E.   Screening and Processing Mail
      1.    US Postal Service
              a. Regulations
              b. Classifications
              c. Types of mail services
              d. Tracing mail
              e. Recalling mail

F.   Private services
       1. Alternate delivery
       2. Fax services

G. Postal machine/meter
H. Processing incoming mail
I. Preparing outgoing mail
     1. Labels
     2. Optical Character Reader (OCR) guidelines

J.   Resource Information and Community Services
K.   Services available
L.   Appropriate referrals
M.   Follow-up
N.   Patient advocate


O.   Communication, Equipment and Supplies
      1.    Adapting communication to an individual’s ability to understand (e.g., patients
            with special needs)
              a. Blind
              b. Deaf
              c. Elderly
              d. Children
              e. Seriously ill
               f. Mentally impaired
              g. Illiterate
              h. Non-English-speaking
               i. Anxious
               j. Angry/distraught
              k. Motor impaired
      2.    Recognizing and responding to verbal and nonverbal communication
              a. Positive body language
              b. Listening skills
              c. Eye contact
              d. to effective communication
              e. Identifying needs of others
      3.    Patient instruction
              a. Explaining general office policies
              b. Instructing individuals according to their needs
              c. Instructing and demonstrating the use and care of patient equipment


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             d. Providing instruction for health maintenance and disease prevention
             e. Identifying community resources
      4.   Professional communication and behavior
             a. Professional situations
             b. tact
             c. diplomacy
             d. courtesy
             e. responsibility
      5.   Therapeutic relationships
             a. impartial behavior
             b. effective responses to cultural differences
             c. empathy
      6.   Evaluating and understanding communication
             a. Observation
             b. Active listening
             c. Feedback
      7.   Interviewing techniques
             a. Guiding, controlling and ending interviews
             b. Using questions (e.g., exploratory, open-ended, and direct)
             c. Specific interviews
             d. interviewee (e.g., patient, family member, others)
             e. setting (e.g., office, telephone, hospital)
              f. Legal restrictions
      8.   Receiving, organizing, prioritizing and transmitting information
             a. Modalities for incoming and outgoing data (e.g., mail, fax, telephone, computer)
             b. Prioritizing incoming and outgoing data (e.g., importance, urgency, recipient
                 availability)
      9.   Telephone techniques
             a. Incoming calls management criteria
             b. screening
             c. effective conversation
             d. maintaining confidentiality
             e. gathering data
              f. multiple-line competency
             g. transferring appropriate calls
             h. screening and referral
              i. identifying caller, office and self
              j. taking messages
             k. ending calls
              l. Monitoring special calls
             m. problem calls (eg, unidentified caller, angry patient, family member)
             n. emergency calls
     10.   Fundamental writing skills
             a. Sentence structure
             b. Grammar
             c. Punctuation
             d. Spelling

P.   Computers in Medical Office-Data Entry
      1.   Keyboard fundamentals and functions
             a. Alpha, numeric and symbol keys
             b. Spacing and margins
             c. Horizontal and vertical centering
             d. Tabulation
      2.   Formats
             a. Letters
             b. Memos
             c. Reports



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             d. Manuscripts
             e. Envelopes
              f. Chart notes
             g. Templates
      3.   Proofreading
             a. Proofreader’s marks
             b. Making corrections from rough draft

Q.   Computer Concepts
      1.   Terminology
      2.   Central processing unit (CPU), monitor, keyboard
      3.   Scanner
      4.   Printers
      5.   Disk drive
      6.   Storage devices (e.g., hard disks, magnetic tapes, CD-ROMs, flash drives)
      7.   Operating systems
      8.   Basic commands
              a. starting a computer
              b. loading a program
              c. formatting a disk
              d. making a back-up copy
              e. exiting and shutting down computer
      9.   Care and maintenance of computer
              a. Main unit and components
              b. Protection/safety
              c. Maintenance agreements
              d. Support
              e. Leasing
     10.   Computer applications
              a. Word processing
              b. Database (e.g., menu, fields, records, files)
              c. Spreadsheets, graphics
              d. Electronic mail
              e. Networks
              f. Multi-user/multi-task system
              g. Security/password
              h. Training programs (e.g., user manual, tutorials, reference cards, help screens)
               i. Medical management software/ Medisoft
                   file maintenance (practice information)
                   new patient entry (demographic data, appointments)
                   diagnostic and procedural code entry
                   payment/entry transaction
                   electronic claims
                   routine billing
                    (i) superbill/ discharge paperwork
                    (ii) itemized statement to third parties
                    (iii) monthly statements
                   report generation
                    (i) Monthly revenue
                    (ii) Accounts receivable
                   utilities
              j. Internet Services

R.   Equipment
      1.   Equipment operation
             a. Calculator
             b. Photocopier
             c. Computer/word processor


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             d. Fax machine
             e. Telephone services and use
                 multi-button telephone
                 types of calls
                 features
             f. Scanners
      2.   Maintenance and repairs
             a. Contents of instruction manual
             b. Routine maintenance
                 agreements
                 warranty
                 repair service

S.   Records Management
      1.   Needs, purposes and terminology of filing systems
              a. Basic filing systems
                   alphabetic
                   numeric
                   geographic
                   subject
              b. Special filing systems
                   color-code
                   tickler file
                   electronic data processing files (EDP)
                   cross-reference/master file
      2.   Process for filing documents
      3.   Organization of patient’s medical record
      4.   Filing guidelines
              a. Storing
              b. Protecting/safekeeping
              c. Transferring
              d. Retaining
              e. Purging
               f. Destroying
      5.   Medical records
              a. Types
                   problem oriented
                   source oriented
              b. Collecting information
              c. Making corrections
              d. Retaining and purging
              e. statute of limitations
               f. deceased patients

T.   Scheduling and Monitoring Appointments
      1.   Utilizing appointment schedules/types
              a. Stream
             b. Wave
              c. Modified wave
             d. Open booking
              e. Categorization
      2.   Appointment guidelines
              a. Legal aspects
             b. New/established patient
              c. Patient needs/preference
             d. Physician preference/habits
              e. Facilities/equipment requirements
      3.   Protocol


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             a.    Follow-up visits
                    routine
                    urgent
             b.    Emergency/acutely ill
             c.    Physician referrals
             d.    Cancellations/no-shows
             e.    Physician delay/unavailability
             f.    Outside services (e.g., lab, x-ray, surgery)
             g.    Reminders/recalls
                    appointment cards
                   tickler file

      4.   Managing Physician’s Professional Schedule and Travel
             a.     Arranging meetings (e.g., dates, facilities, accommodations)
             b.     Scheduling travel
             c.     Integrating meetings and travel with office schedule

U.   Managing the Office
      1.   Maintaining the physical environment of the office
              a. Office environment (e.g., arrangement of furniture, equipment and supplies)
             b. Personnel
                     recruiting
                     interviewing
                     hiring
                     evaluating performance
                     disciplining
                     terminating
                     documenting
      2.   Facilities and equipment
              a. maintenance and repair
             b. safety regulations
              c. Occupational Safety and Health Act (OSHA)
             d. Centers for Disease Control and Prevention(CDC) guidelines
              e. Americans with Disabilities Act (ADA)
              f. fire regulations
             g. security systems
      3.   Equipment and supply inventory
              a. Inventory control
             b. Storage and security
              c. Purchasing
      4.   Maintaining liability coverage
              a. Types of coverage
             b. Recordkeeping

V.   Professionalism
      1.   Displaying professional attitude
              a. Supporting professional organization
              b. Accepting responsibility for own actions
      2.   Job readiness and seeking employment
              a. Résumé and cover letter
              b. Methods of job searching
              c. Interviewing as a job candidate
              d. Professional presentation
      3.   Performing within ethical boundaries
              a. Ethical standards
                    AAMA Code of Ethics
                    AMA Code of Ethics
      4.   Patient rights


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           5.   Current issues in medical bioethics
           6.   Maintaining confidentiality
                   a. Agent of physician
                         patient rights
                         releasing patient information
                   b. Intentional tort
                         invasion of privacy
                         slander and libel
           7.   Working as a team member to achieve goals
           8.   Member responsibility
           9.   Promoting competent patient care
          10.   Utilizing principles of group dynamics

          11.   Time management
                  a. Establishing priorities
                  b. Managing routine duties

W.        Office Policies and Procedures
     1.    Patient information booklet
     2.    Patient education
     3.    Instructions for patients with special needs
     4.    Personnel manual
     5.    Policy and procedures manuals/protocols
     6.    Compliance plan

X.        Managing Practice Finances
     1. Bookkeeping systems (e.g., single, double entry, pegboard, computer)
        a. Demographic data
        b. Day sheets, charge slips, receipts, ledgers, etc.
             (1) charges, payments and adjustments
             (2) transactions
             (3) identifying and correcting errors
        c. Petty cash
     2. Coding systems
        a. Types
             (1) Current Procedural Terminology (CPT)
             (2) International Classification of Diseases, Clinical Modifications (ICD-CM) (current
                   schedule)
             (3) Healthcare Financing Common Procedural Coding System (HCPCS Level II)
        b. Relationship between procedures and diagnosis codes
     3. Third-party billing
        a. Types
             (1) capitated plans
             (2) commercial carriers
             (3) government plans
                (a) Medicare
                (b) Medicaid
                (c) CHAMPUS/Tricare
                (d) CHAMPVA
             (4) prepaid HMO, PPO, POS
             (5) workers compensation
        b. Processing claims
             (1) manual and electronic preparation of claims
             (2) tracing claims
             (3) sequence of filing (e.g., primary vs. secondary)
             (4) reconciling payments/rejections
             (5) inquiry and appeal process
        c. Applying managed care policies and procedures


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              (1) referrals
              (2) precertification
              (3) contracts and fees
         d. Fee schedules
              (1) methods for establishing fees
                 (a) Relative Value Studies
                 (b) Resource-based Relative Value Scale (RBRVS)
                 (c) Diagnosis Related Groups (DRGs)
              (2) updating fee schedules
      4. Accounting and banking procedures
         a. Accounts receivable
              (1) collecting/updating demographic data
              (2) billing procedures
                 (a) itemization
                 (b) billing cycles
              (3) aging/controlling accounts receivable
              (4) collection procedures
                 (a) collection analysis
                 (b) office collection efforts
                 (c) collection agencies
                 (d) consumer protection acts
         b. Accounts payable
              (1) ordering goods and services
              (2) monitoring invoices
              (3) tracking merchandise
              (4) paying accounts
              (5) writing checks
         c. Banking procedures
              (1) processing accounts receivable
              (2) preparing bank deposit
              (3) electronic banking
              (4) reconciling bank statement
              (5) maintaining financial records
      5. Employee payroll
         a. Maintaining payroll records
         b. Calculating wages and taxes
         c. Preparing payroll checks and earning statements
         d. Depositing taxes
         e. Filing and mailing tax reports


II.       Theory
 A.     Medical Terminology
         1.   Word building and definitions
                 a. roots or stems
                 b. prefixes
                 c. suffixes
                 d. plurals
                 e. abbreviations
                 f. symbols
         2.   Surgical procedures
         3.   Diagnostic procedures
         4.   Medical specialties
         5.   Common diseases and pathology
         6.   Uses of terminology
                 a. Spelling and pronunciation
                 b. Selection and use (eg, data entry, reports, records, documents, patient education,
                     correspondence, medicolegal documentation, letters, memos, messages, facsimiles)



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               c. Reference sources
        7.   Abbreviations
                a.   Medical Charting
                b.   Medication and Rx abbreviations
                c.   Lab tests and X-ray abbreviations


B.     Nutrition
        1.   Basic principles
               a. Food pyramid
               b. Food elements (ie, vitamins, minerals)
        2.   Special needs
               a. Diets
               b. Restrictions


C.     Pharmacology Preparing and Administering Medications
     (For the most commonly used medications visit http://www.rxlist.com/top200.htm)

        1.   Pharmacology
                a. Classes of drugs
                b. Drug forms
                c. Drug action/uses
                d. Side effects/adverse reactions
                e. Emergency use
                f. Substance abuse
                g. Calculation of dosage
                h. Immunizations
        2.   Preparing and administering oral and parenteral medications
        3.   Prescriptions
                a. Prescription parts- superscription, inscription, subscription
                b. Safekeeping
                c. Recordkeeping
                d. Reordering
                e. Schedule of Controlled substances
        4.   Maintaining medication and immunization records
        5.   Medication disposal
        6.   Principles of IV therapy
                a. Terminology
                b. Theory (excludes administration of IV medications)

        7.   Anatomy and Physiology
               a.    Quadrants and Planes
               b.    Cells and tissue structure and physiology
               c.    Integumentary System
               d.    Musculoskeletal System
               e.    Nervous System
                f.   Cardiovascular System
               g.    Respiratory System
               h.    Digestive System
                i.   Endocrine System
                j.   Sensory System
               k.    Urinary System
                l.   Reproductive System
               m.    Common diseases and pathology




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 D.        Psychology
      1. Basic principles
         a. Meaning of individual self-worth
         b. Understanding human behavior—Maslow’s hierarchy of needs
         c. Social needs of people
         d. Understanding emotional behavior
      2. Developmental stages of the life cycle
         a. Developmental theories used to explain behavior and development
         b. Human growth and development
      3. Hereditary, cultural, and environmental influences on behavior
         a. Helping patients adjust to illness
         b. Cultural influences on behavior
         c. Importance of recognizing cultural differences and attitudes toward the health care
            system
         d. Recognizing social and environmental influences on behavior
      4. Defense mechanisms
      5. Recognition
         a. Management

 E.        Patient History Interview
      1.    Components of patient history
            a. Personal data
            b. Chief complaint
            c. Past, present, family and social history
            d. Review of systems
      2.    Documentation guidelines


III. Clinical Skills
 A.        Collecting and Processing Specimens; Diagnostic Testing
 B. Methods of collection
      1. Blood
             a. vein
             b. capillary
      2. Urine
      3. Stool
      4. Sputum
      5. Cultures
             a. throat
             b. vaginal
             c. wounds
             d. urine
             e. blood
 C. Processing specimens
      1. Centers for Disease Control and Prevention(CDC) guidelines
      2. Proper labeling
      3. Contamination
      4. Specimen preservation
      5. Recordkeeping
 D. Quality control
 E. Performing selected tests

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      1.  Urinalysis
             a. physical
             b. chemical
             c. microscopic
     2. Hematology
             a. hematocrit
             b. hemoglobin
             c. erythrocyte sedimentation rate
             d. automated cell counts
                  red blood cell (RBC)
                  white blood cell (WBC)
                  platelet
             e. coagulation testing
     3. Blood chemistry
             a. glucose
             b. kidney function tests
             c. liver function tests
             d. lipid profile
     4. Immunology
             a. mono test
             b. strep test
     5. Pregnancy testing
     6. Microbiology
             a. theory/terminology
             b. cultures
                  blood
                  urine
                  vaginal
                  wound
                  throat
                  stool
             c. Gram’s staining
     7. Tuberculosis testing
     8. Electrocardiography (EKG/ECG)
     9. Guiac testing
F. Vision testing
G. Hearing testing
H. Respiratory testing
     1. Pulmonary function
     2. Spirometry
     3. Pulse oximetry
     4. Nebulizer treatment
I. Medical imaging
     1. Terminology
     2. Safety principles
     3. Patient preparation
J. Patient Prep
     1. Vital Signs
     2. Patient positioning
     3. eye exam

K. Treatment Area
L. Equipment preparation and operation
M. Principles of operation
     1. Autoclave/sterilizer
     2. Cast equipment/materials
     3. Electrocardiograph
     4. Examination tables
     5. Microscope


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     6. Ophthalmoscope/otoscope/stethoscope
     7. Oxygen
     8. Physical therapy modalities
     9. Endoscopes
    10. Scales
    11. Sphygmomanometers
    12. Spirometer
    13. Thermometers
    14. Nebulizers
    15. Wheelchair/stretcher
N. Restocking supplies
O. Preparing/maintaining treatment areas
P. Safety precautions

Q.   Principles of Infection Control
      1.   Principles of asepsis
      2.   Aseptic technique
              a. Medical asepsis
                  handwashing
                  sanitization
                  chemical disinfection
              b. Surgical asepsis
                  scrubbing
                  gowning
                  gloving
                  surgical assisting
                  preparing equipment
                  preparing items for autoclave
                  performing sterilization techniques
      3.   Disposal of biohazardous material
      4.   Practice Standard Precautions

R.   Emergencies
      1.   Preplanned action
             a. Policies and procedures
             b. Legal implications and action documentation
             c. Equipment
      2.   Assessment and triage

S.   First Aid
      1.   Establishing and maintaining an airway
      2.   Identifying and responding to:
              a. Bleeding/pressure points
             b. Burns
              c. Cardiac and respiratory arrest/CPR
             d. Choking/Heimlich maneuver
              e. Diabetic coma/insulin shock
              f. Fractures
             g. Poisoning
             h. Seizures
              i. Shock
              j. Syncope
             k. Wounds
      3.   Signs and symptoms
      4.   Management




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