CCMA general pt care

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Author:
PopeJim
ID:
264328
Filename:
CCMA general pt care
Updated:
2014-02-27 22:57:22
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CCMA general pt care
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CCMA general pt care
Description:
CCMA general pt care
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  1. ensure correct pronuncation
    ask the receptionist
  2. ask to please state and spell first and last name, DOB, & last 4 of social
    to properly ID
  3. applies to any person who registers as a pt
    HIPAA
  4. NEVER personally assist
    ask to carry any bags or get a walker or wheelchair
  5. what is name, medical record #, DOB, SSN, ins policy #, photos or images
    protected health information (PHI) that can identify a pt
  6. use ____ permanent ink
    black
  7. subject=statement of sypmtom & complaints (cc), reason for encounter
    S of SOAP
  8. objective=all findings from date of examination
    O of SOAP
  9. assessment=medical decision using S&O findings to obtain a Dx
    A of SOAP
  10. plan=Tx, documenting a plan of care
    P of SOAP
  11. encounter form or Superbill
    CMS-1500
  12. who is the only person able to discuss medical info w/ the pt
    doctor
  13. what kind of photo ID
    state issued
  14. used to record measurements & observations made every shift or 3-4 x's a day (all vital signs & Dr's visits).
    graphic sheet
  15. used to record frequent measurements or observations such a BP (q15 mins)
    flow sheets
  16. history of present illness
    HPI
  17. past family & social histories
    PFSH
  18. past history
    PH
  19. family history
    FH
  20. social history
    SH
  21. examine using touch
    palpation
  22. tapping or striking the body
    percussion
  23. listening to sounds produced by internal organs
    auscultation

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