Definitions to know
Cytotechnologist |
Examines cellular abnormalities |
Pylorotomy |
Perfformed in gastrointestinal system |
Thoraces |
Chest |
Rhinorrhea |
Drainage from the nose |
Cranioplasty |
Surgical repair of the skull |
Malaise |
General sense of weakness, discomfort, fatigue or feeling run down that may occur alone or with another symptom |
Intradermal Injection |
Places a small amount of a drug just under the outer layer of the skin |
Hypothermia |
Drop in body temperature during prolonged exposure to cold |
A compound fracture |
A fracture of bone where the broken end has penetrated the skin |
Calporrhaphy |
The repair of the vagina |
Arthralgia |
Pain in a joint |
Gastroenterology |
The study of the stomach, intestines and associated diseases |
Lumbar |
Lower back |
Chondrocostal |
Cartilage and ribs |
Hypotension |
Decreased blood pressure |
Phlebectomy |
Removal of a vein or segment of a vein |
Living Will |
Legal document addressed to patient's family and physicians stating what type of treatment the patient wishes or does not wish when terminally ill |
Melanoma |
Cancerous Tumor |
The Hippocratic Oath |
To use the form of treatment believed best for patient, refrain from harmful actions, keep patient's private information confidential |
Retention Schedule |
Determining how long to keep patients records after they become inactive or closed |
Cell Phone Message
Message for |
doctor |
Date |
Current date |
Patient name |
patient name |
Description |
reason patient is calling |
Next step |
check box |
Message taken by |
Contestant number |
|
|
Procedures
Obtained from new patients |
Patients full legal name, address and telephone numbers, reason for visit |
Numeric filing |
Preserves patient confidentiality |
Any information released from a medical record |
Requires patient notification and approval |
Co-pay |
Portion of medical fees patient needs to pay at time of service |
Exclusions |
Noncovered services |
HIPAA |
Confidentiality, privacy, security of information, national standards for electronic healthcare transactions |
Beneficiary |
Person covered under insurance policy |
Coordination of Benefits |
Determines which of the policies will pay first when more than one policy covers the individual |
Provider's Fee Schedule |
Continous record of usual charges made for specific services |
The guarantor |
If divorced, the parent who has physical custody is responsible for payment |
The appropriate time to discuss fees for financial concern |
When scheduling an appointment |
Medical history form includes: |
social history, medical history, family history, review of symptoms and chief complaint |
SOAP Transcript
Subject |
Patient name, date of birth, seen by, date, reason for visit, length of symptoms, extra info |
Objective |
History, meds, examination and what it showed, test perfformed |
Asessment |
Based on patient's report and physical examinatin diagnosis is... |
Plan |
Future plan for patient |
Abbreviations
Tx |
Treatment |
Dx |
Diagnosis |
Rx |
Prescription |
ENT |
Ear, nose and throat |
DOB |
Date of birth |
p.r.n |
when necessary or as needed |
DOS |
date of service |
OTC |
over the counter |
CPR |
Cardiopulmonary resuscitation |
H&P |
history and physical |
Pt |
Patient |
HR |
heart rate |
CC |
Chief complaint |
PPO |
Preffered provider organization |
Wt |
Weight |
N&V |
nausea and vomiting |
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