AMCA Certification Exam

AMCA Certification Exam Empathy Having an understanding and compassion for what the patient may be experiencing Established Patient Has been seen by the physician within 3 years New Patient Hasn't been to the physician in 3 years CMS Center for Medicare and Medicaid services HIPAA Title I Healthcare Access, Portability and Renewability HIPAA Title II Preventing Health Care Fraud and Abuse HIPAA Title III Tax Related Health Provisions HIPAA Title IV Application and Enforcement of Group Health Plan Requirements HIPAA Title V Revenue Offsets HIPAA Health Insurance and Accountability Act Expressed Consent A patient acknowledges that they have received proper direction regarding the nature of their medical treatment verbally or by signing a comment form Implied Consent A patient uses body language top indicate that they agree to receive a form of medical care Respondeat Superior "let the master answer"; physician is responsible for medical staff mistakes Coordination of Benefits C.O.B; Indicates how a policy well pay when more than one insurance plan is in effect HITECH Health Information Technology for Economic and Clinical Health Act; Promotes the adoption and meaningful use of health information technology (EHR) ONCHIT Office of National Coordination for Health Technology Core Function of EHR Health Information and data elements Core Function of EHR Results management Core Function of EHR Order management Core Function of EHR Decision support Core Function of EHR Electronic communications and connectivity Core Function of EHR Patient support Core Function of EHR Administrative processes Core Function of EHR Reporting and population management Electronic Medical Records (EMR) Computerized records of one physicians encounter with a patient over time (intranet) Electronic Health Records (EHR) Reflects the data from ALL sources that have treated the individual (interoperable to other facilities) Acute Care Most often refers to a hospital, treats patients with urgent problems that cannot be handled Personal Health Records (PHR) Maintained and owned by the patient Ambulatory Care Refers to treatment without admission to hospital Clinical Templates Allows doctors to document patient encounters into an EHR on a structured form RADT Registration, admissions, discharge, transfer Unique Patient Identifier (UPI) Links all clinical observations, tests, procedures, villains, evaluations, and diagnoses to the patient Clinical Vocabularies Set a common definitions for medical terms that ease communication by decreasing uncertainty SNOMED-CT Clinical vocabulary designed to encompass all trends used in medicine LOINC Trends and codes used for electronic exchange of lab results and clinical observations UMLS Thesaurus database of medical terms Fixed Appointment Scheduling One patient is scheduled for a specific appointment time Cluster Scheduling Scheduling a group of patients cooking in for the fake tour of service should be scheduled around the same block of time Double Booking Two patients are scheduled to see the same physician at once Wave Scheduling Method Patients are scheduled for the first half of each hour, and each patient is seen in the order they arrive Narrative Style Charting Physicians dictate notes about patients care, then gave rise notes transcribed and placed in the patients chart SOAP Subjective, objective, assessment, plan Subjective Any information that the patient provides including chief complaint, or comments made during an examination Objective Information based on observations made by the physician or medical assistant (lab results, vital signs) Assessment A brief summary of the patients symptoms, and may often include a diagnosis as well as a list of other possible diagnoses Plan Consists of any information regarding the prescribed plan of action for a patient (prescriptions, instructions, referrals) Problem Oriented Medical Record (POMR) Charting that tracks patients problems during the time they are receiving medical care Progress Notes Daily chart notes which are used to record any information that Irish to the various stages of a patients condition Flow Chart A visual aid used to keep track of information over a period of time Alphabetic Filing System Information is filed according to the patients last name Numeric Filing System Information regarding each patient is stored used a number, instead of the last name A Medical Record Contains... Personal information, financial information, medical information and social information Personal/Financial Information Includes insurance data, marital status, next of kin, and other items collected for personal identification Medical Information Includes the chief complaint, family/patient medical history, results of exams, physical exam form, lab reports, etc. Social Information Includes items such as race, ethnicity, hobbies, lifestyle choices Self-Insure A method in which the employer pays directly for the employees medical bills Medicare Federal program for patients that are either over the age of 65, disabled, or considered end-stage renal disease patients Medicaid Federal program, state administered, for individuals/families that have very low income TRICARE