Management Duties 1 Informatics 2 1 4 ICD -9-CM …images.pcmac.org/.../3.02_Understand_health_informatics_worksheets.pdfmedical terminology 3-Apply information for regulatory and

7242 Health Science II Summer 2011 Page 237

3.02 Understand health informatics Name___________________ Handout Date ______ ______________ Directions: Record notes and class discussion in your own words. Compare the ICD-9-CM and CPT codes as you view the PowerPoint presentation.

Health Informatics

Health Informatics

Management Duties 1 2 3 4

Technical Duties 1 2 3 4

Health Informatics

Professionals

1

2

3

4

5

Analyze patient information

1

2

3

4

Abstract and code patient information

1 2 3

ICD-9-CM Coding

CPT Coding

http://icd9cm.chrisendres.com/

http://www.findacode.com/search/search.php


3.02 Understand health informatics Name____________________ Handout KEY Date _______ _____________ Directions: Record notes and class discussion in your own words. Compare the ICD-9-CM and CPT codes as you view the PowerPoint presentation.

Health Informatics

Health Informatics

Management Duties 1-Design and develop information systems needed for medical records and insurance 2-Develop policies and procedures for handling medical information to ensure patient privacy and security 3-Stay within budget 4-Train users

Technical Duties 1-Design and develop information systems that operate between healthcare facilities 2-Integrate all medical records and insurance requirements into one user-friendly system 3-Develop information systems that adhere to policies and procedures for handling information to ensure patient privacy and security

Health Informatics

Professionals

1. Analyze information 2. Abstract and code patient information 3. Communicate information 4. Document information 5. Manage health information systems

Analyze patient information

-Determine health information required -Collect required information -Evaluate the information -Report and distribute information within legal guidelines

Abstract and code patient information

1-Collect information to record charges and reimbursements 2-Use appropriate medical terminology 3-Apply information for regulatory and legal purposes

ICD-9-CM Coding

CPT Coding

http://icd9cm.chrisendres.com/

http://www.findacode.com/search/search.php


3.02 What’s the Main Term? Name___________________ Handout Date _____ _______________

Directions: Using the ICD-9-CM for reference, identify and underline the main term in each diagnosis listed below.

1. Open fracture, maxilla

2. Congenital diaphragmatic hernia

3. Diaper rash

4. Dysplasia of the cervix

5. Sleep apnea

6. Intracranial abscess

7. Congestive heart failure

8. Acute cystitis

9. Chronic maxillary sinusitis

10. Impacted feces

11. Upper respiratory infection

12. Irritability of the stomach

13. Elevated blood pressure

14. Nontraumatic rupture of Achilles tendon

15. Diabetic cataract

16. Cushing’s Syndrome

17. Vitamin B12 deficiency

18. Trench mouth

19. Webbed toes

20. Intrinsic asthma in status asthmaticus


3.02 What’s the main term? Name___________________ Handout KEY Date ______________ ______

Directions: Using the ICD-9-CM for reference, identify and underline the main term in each diagnosis listed below.

1. Open fracture, maxilla

2. Congenital diaphragmatic hernia

3. Diaper rash

4. Dysplasia of the cervix

5. Sleep apnea

6. Intracranial abscess

7. Congestive heart failure

8. Acute cystitis

9. Chronic maxillary sinusitis

10. Impacted feces

11. Upper respiratory infection

12. Irritability of the stomach

13. Elevated blood pressure

14. Nontraumatic rupture of Achilles tendon

15. Diabetic cataract

16. Cushing’s Syndrome (Either)

17. Vitamin B12 deficiency

18. Trench mouth

19. Webbed toes

20. Intrinsic asthma in status asthmaticus


3.02 ICD-9-CM Coding Name ___________________ Handout Date ____________________

Directions: Use the ICD-9-CM Code book to assign the correct ICD-9-CM codes for the following diagnoses. Follow the Basic Steps of ICD-9-CM Coding.

1. Allergic diarrhea __________

2. Cholesterolosis of gallbladder __________

3. Urethral chancre __________

4. Cystic fibrosis __________

5. Congestive rheumatic heart failure __________

6. Viral meningitis __________

7. Cleft lip and palate __________

8. Pancytopenia __________

9. Infantile cerebral palsy __________

10. Anal fistula __________

11. Acne vulgaris __________

12. Dermatophytosis of the foot __________

13. Hiatal hernia with obstruction and gangrene __________

14. Mitral valve insufficiency __________

15. Monocytic leukocytosis __________

16. Lung mass __________

17. Prolapse of the bladder, female __________

18. Rupture of the gallbladder __________

19. Venereal warts __________

20. Gouty arthritis __________


3.02 ICD-9-CM Coding Name ___________________ Handout KEY Date ____________________

Directions: Use the ICD-9-CM Code book to assign the correct ICD-9-CM codes for the following diagnoses. Follow the Basic Steps of ICD-9-CM Coding.

1. Allergic diarrhea __558.3__

2. Cholesterolosis of gallbladder __575.6___

3. Urethral chancre __091.0___

4. Cystic fibrosis __277.00__

5. Congestive rheumatic heart failure __398.91__

6. Viral meningitis __047.9___

7. Cleft lip and palate __749.20__

8. Pancytopenia __284.1___

9. Infantile cerebral palsy __343.9___

10. Anal fistula __565.1___

11. Acne vulgaris __706.1___

12. Dermatophytosis of the foot __110.4___

13. Hiatal hernia with obstruction and gangrene __551.3___

14. Mitral valve insufficiency __424.0___

15. Monocytic leukocytosis __288.8___

16. Lung mass __786.6___

17. Prolapse of the bladder, female __618.01__

18. Rupture of the gallbladder __575.4___

19. Venereal warts __078.11__

20. Gouty arthritis __274.00__


3.02 CPT Coding Name ___________________ Handout Date ____________________

Directions: Use the CPT Code book to assign the correct CPT code for the following procedure/service. Follow the Basic Steps of CPT Coding.

1. Arthrography of the knee, supervision and interpretation __________

2. Lipid panel blood test __________

3. Breast abscess, incision and drainage __________

4. Pneumocentesis __________

5. Closed reduction of closed fracture, clavicle, without manipulation __________

6. Influenza vaccine, age 3 years old (preservative free) __________

7. Bacteria culture, urine __________

8. Stool for occult blood __________

9. X-ray pelvis, 4 views __________

10. Bilateral screening mammography ____________________

11. Diagnostic arthroscopy, right wrist, with synovial biopsy __________

12. Laparoscopic cholecystectomy with cholangiography __________

13. Anesthesia services for hernia repair in the lower abdomen __________

14. Dilation of cervical canal __________

15. Molar pregnancy excision __________

16. Electrosurgical removal, 12 skin tags __________

17. Magnetic resonance imaging (MRI), lumbar spine with contrast __________

18. Needle core biopsy of lung __________

19. Destruction of 8 warts __________

20. Repair of complex, open wound of scalp; 2.8 cm __________


3.02 CPT Coding Name ___________________ Handout KEY Date ____________________

Directions: Use the CPT Code book to assign the correct CPT code for the following procedure/service. Follow the Basic Steps of CPT Coding.

1. Arthrography of the knee, supervision and interpretation __73580___

2. Lipid panel blood test __80061___

3. Breast abscess, incision and drainage __19020___

4. Pneumocentesis __32420___

5. Closed reduction of closed fracture, clavicle, without manipulation __23500___

6. Influenza vaccine, age 3 years old (preservative free) __90656___

7. Bacteria culture, urine __87086___

8. Stool for occult blood __82270___

9. X-ray pelvis, 4 views __72190___

10. Bilateral screening mammography __77057___

11. Diagnostic arthroscopy, right wrist, with synovial biopsy __29840___

12. Laparoscopic cholecystectomy with cholangiography __47563___

13. Anesthesia services for hernia repair in the lower abdomen __00830___

14. Dilation of cervical canal __57800___

15. Molar pregnancy excision __59100___

16. Electrosurgical removal, 12 skin tags __11200___

17. Magnetic resonance imaging (MRI), lumbar spine with contrast __72149___

18. Needle core biopsy of lung __32405___

19. Destruction of 8 warts __17110___

20. Repair of complex (open) wound of scalp; 2.8 cm __13121___


3.02 Understand health informatics II Name___________________ Handout Date _____ _______________

Directions: Record notes and class discussion in your own words.

Document information

Career Responsibilities Class Discussion

Communicate information

Manage health information

systems


3.02 Understand health informatics II Name___________________ Handout Date ______ ______________

Directions: Record notes and class discussion in your own words.

Document information

Career Responsibilities Class Discussion

-Complete insurance forms

-Communicate information

-Use technology

-Schedule appointments

-Complete medical records forms

-Maintain accounting records

Communicate information

-File records

-Use technology

-Schedule appointments

-Complete medical records

-Maintain accounting records

Manage health

information systems

-Combine the information systems used within a healthcare agency -Enable timely and accurate flow of information -Organize information within guidelines -Participate in the design of operational systems -Evaluate operational systems


3.02 Using Medical Abbreviations Name ________________________ Handout Date ________________________ Directions: Translate the following patient scenario and rewrite the scenario using the definition of the abbreviation. Underline the definition. Katie was admitted to the ED with complaints of FUO, N/V, and SOB. She had had nothing po because the sx became worse pc . A CBC, UA, and BS were ordered. An intravenous line was started and she was made NPO. Her TPR was normal but her P had increased. After a few hours, it was determined that she could be OOB and the order for BR was discontinued. She was placed on cl liq and received more than gtts for lunch. Her initial Dx of R/O salmonella was amended as she tolerated the liquids. When all lab work returned WNL, she was discharged. On the way out of the ED, she had to complete the paperwork with her DOB and was given a Rx for nausea. ______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________


3.02 Using Medical Abbreviations N ame ________________________ Handout KEY Date _________________________ Directions: Translate the following patient scenario and rewrite the scenario using the definition of the abbreviation. Underline the definition. Katie was admitted to the ED with complaints of FUO, N/V, and SOB. She had had nothing po because the sx became worse pc . A CBC, UA, and BS were ordered. An intravenous line was started and she was made NPO. Her TPR was normal but her P had increased. After a few hours, it was determined that she could be OOB and the order for BR was discontinued. She was placed on cl liq and received more than gtts for lunch. Her initial Dx of R/O salmonella was amended as she tolerated the liquids. When all lab work returned WNL, she was discharged. On the way out of the ED, she had to complete the paperwork with her DOB and was given a Rx for nausea. Katie was admitted to the emergency department with complaints of fever of unknown origin, nausea and vomiting, and shortness of breath. She had had nothing by mouth because the symptoms became worse after meals. A complete blood count, urinalysis, and blood sugar were ordered. An intravenous line was started and she made nothing by mouth. Her temperature, pulse, and respiration was normal but her pulse had increased. After a few hours, it was determined that she could be out of bed and the order for bedrest was discontinued. She was placed on clear liquids and received more than drops for lunch. Her initial diagnosis of rule out salmonella was amended as she tolerated the liquids. When all lab work returned within normal limits, she was discharged. On the way of the ED, she had to complete the paperwork with her date of birth and was given a prescription for nausea.


3.02 Medical Abbreviations Name ________________ ___ Handout Class ______ _____________ a before ac before meals ad lib as desired ax axillary BR bedrest BS blood sugar BSE breast self-exam CBC complete blood count cl liq clear liquids DNR do not resuscitate DOA dead on arrival DOB date of birth Dx, dx diagnosis ED emergency department FUO fever of unknown origin gtt drop NPO nothing by mouth N/V, N&V nausea and vomiting p after P pulse OOB out of bed pc after meals po by mouth R respiration R/O rule out ROM range of motion Rx treatment SOB shortness of breath Sx symptom T, temp temperature TPR temperature, pulse, respiration UA, U/A urinalysis WNL within normal limits


3.02 Medical Abbreviations Quiz Name ______________________ Handout Date _______________________ Directions: Write the meaning of the following abbreviations: 1. ad lib ____________________________ 2. ax ____________________________ 3. ac ____________________________ 4. BSE ____________________________ 5. DNR ____________________________ 6. DOA ____________________________ 7. R ____________________________ 8. ROM ____________________________ 9. T ____________________________ 10. UA ____________________________ 11. FUO ____________________________ 12. P ____________________________ Directions: Write the abbreviation for the following medical terms: 1. bedrest ____________________________ 2. blood sugar ____________________________ 3. complete blood count _______________________ 4. clear liquids ____________________________ 5. date of birth ____________________________ 6. diagnosis ____________________________ 7. emergency department _______________________ 8. drop ____________________________ 9. nothing by mouth____________________________ 10. nausea and vomiting _______________________ 11. out of bed ____________________________ 12. after meals ____________________________ 13. by mouth ____________________________ 14. respiration ____________________________ 15. rule out ____________________________ 16. range of motion ____________________________ 17. treatment ____________________________ 18. shortness of breath _________________________ 19. symptom ____________________________ 20. temperature ____________________________ 21. within normal limits _________________________


3.02 Medical Abbreviations Quiz Name ______________________ Handout K EY Date _______________________ Directions: Write the meaning of the following abbreviations: 1. ad lib _as desired___________________ 2. ax axillary______________________ 3. ac _before meals_________________ 4. BSE _breast self-exam______________ 5. DNR _do not resuscitate_____________ 6. DOA _dead on arrival_______________ 7. R _respiration___________________ 8. ROM _range of motion_______________ 9. T _temperature__________________ 10. UA _urinalysis____________________ 11. FUO _fever of unknown origin_________ 12. P _pulse_______________________ Directions: Write the abbreviation for the following medical terms: 1. bedrest _BR____________________________ 2. blood sugar _BS____________________________ 3. complete blood count _CBC_______________________ 4. clear liquids _cl liq___________________________ 5. date of birth _DOB___________________________ 6. diagnosis _dx_____________________________ 7. emergency department _ED_______________________ 8. drop _gtt_____________________________ 9. nothing by mouth _NPO__________________________ 10. nausea and vomiting _N&V_______________________ 11. out of bed _OOB___________________________ 12. after meals _pc_____________________________ 13. by mouth _po_____________________________ 14. respiration _R______________________________ 15. rule out _r/o_____________________________ 16. range of motion _ROM___________________________ 17. treatment _Rx_____________________________ 18. shortness of breath _SOB________________________ 19. symptom _sx_____________________________ 20. temperature _T______________________________ 21. within normal limits _WNL________________________


3.02 Proofreading Exercise Name ____________ _______ Handout Date ___________ _________

Directions: In the record below, circle misspelled words and identify missing words. Underline the misspelled words and write the corrected and missing words in the appropriate blanks. Consult medical and English dictionaries as necessary.

1. The labratory testing of blood, urine, and 1. ________________________

2. other body fliuds and waste products plays a 2. ________________________

3. miner roll in modern diagnostic medicine. 3. ________________________

4. The number of availabel tests increases 4. ________________________

5. almost daily, and the range of diseses and 5. ________________________

6. conditions able to be tested in labratory 6. ________________________

7. studys continually broadens. Some mention 7. ________________________

8. of labratory test results appears frequently 8. ________________________

9. in history, in physical examintion reports 9. ________________________

10. and nearly always in hospital discharge 10. _______________________

11. summarys. Accordingly the medical 11. _______________________

12. transcirptionist must be familiar with the 12. _______________________

13. general conceps of laboratory medicine as 13. _______________________

14. well as with pecific tests. Diagnostic 14. _______________________

15. labratory procedures may be called tests, 15. _______________________

16. studies, or simply work (“lab studies, “ “lab 16. _______________________

17. word”). Phisicians may report that they 17. _______________________

18. ordered, got, ran, did, or (in the case of 18. _______________________

19. blood work) drew a test. 19. _______________________

20. Crohn’s disease is a chronic dysorder 20. _______________________

21. which consists of inflamation of the 21. _______________________

22. gastrointestinal track. It is most commonly 22. _______________________


23. inflamation of the terminal ilium. The 23. _______________________

24. exact cause is unknown, but possible 24. _______________________

25. causes are allerges, imune 25. _______________________

26. disorders, and infections. Labratory tests 26 _______________________

27. have not detected any bacteria or virus 27. _______________________

28. responsable for causing Crohn’s disease. 28. ________________________

29. The patient experiences cramping, 29. _______________________

30. abdominal pain, nausea, diarrhea, 30. _______________________

31. abdominal tenderness, and weekness. 31. _______________________

32. Patience may be given intervenous fluids 32. _______________________

33. to provide nutrition while resting the bile. 33. _______________________

34. Some patients require surgery if the bile 34. _______________________

35. perforates,obstructs, or if there is 35. _______________________

36. massive hemorhage. 36. _______________________


3.02 Proofreading Exercise Name ____ _______________ Handout KEY Date ____________ ________

Directions: In the record below, circle misspelled words and identify missing words. Underline the misspelled words and write the corrected and missing words in the appropriate blanks. Consult medical and English dictionaries as necessary.

1. The labratory testing of blood, urine, and 1. _laboratory___________________

2. other body fliuds and waste products plays a 2. _fluids_______________________

3. miner roll in modern diagnostic medicine. 3. _minor role___________________

4. The number availabel tests increases 4. _of available__________________

5. almost daily, and the range of diseses and 5. _diseases____________________

6. conditions able to be tested in labratory 6. _ laboratory___________________

7. studys continually broadens. Some mention 7. _studies______________________

8. of labratory test results appears frequently 8. _laboratory___________________

9. in history, in physical examintion reports 9. _examination_________________

10. and nearly always in hospital discharge 10. ____________________________

11. summarys. Accordingly the medical 11. _summaries__________________

12. transcirptionist must be familiar with the 12. _transcriptionist_______________

13. general conceps of laboratory medicine as 13. _concepts____________________

14. well as with pecific tests. Diagnostic 14. _specific_____________________

15. labratory procedures may be called tests, 15. _laboratory___________________

16. studies, or simply work (“lab studies, “ “lab 16. ____________________________

17. word”). Phisicians may report that they 17. _work phycisians______________

18. ordered, got, ran, did, or (in the case of 18. ____________________________

19. blood work) drew a test. 19. ____________________________

20. Crohn’s disease is a chronic dysorder 20. _disorder____________________

21. which consists of inflamation of the 21. ____________________________

22. gastrointestinal track. It is most commonly 22. _tract________________________


23. inflamation of the terminal ilium. The 23. ____________________________

24. exact cause is unknown, but possible 24. ____________________________

25. causes are allerges, imune 25. _allergies, immune_____________

26. disorders, and infections. Labratory tests 26 _laboratory___________________

27. have not detected any bacteria or virus 27. ____________________________

28. responsable for causing Crohn’s disease. 28. _responsible__________________

29. The patient experiences cramping, 29. ____________________________

30. abdominal pain, nausea, diarrhea, 30. ____________________________

31. abdominal tenderness, and weekness. 31. _weakness___________________

32. Patience may be given intervenous fluids 32. _intravenous_________________

33. to provide nutrition while resting the bile. 33. _bowel______________________

34. Some patients require surgery if the bowl 34. _bowel______________________

35. perforates, obstructs, or if there is 35. ____________________________

36. massive hemorhage. 36. _hemorrhage_________________


3.02 Medical Insurance Key Terms Name___________________ Handout Dat e ___________________

Key Term Definition Student Notes

abstracting collecting information from a medical record

claims attachment medical report attached to the claim form substantiating a medical condition

coding assignment of a code to the patient’s diagnoses, procedures for the purpose of reimbursement

ICD-9-CM International Classification of Diseases, 9th Revision, Clinical Modification – coding system used to report diagnoses and reasons for encounters, such as an annual physical examination, on outpatient and physician office claims

CPTa Current Procedural Terminology – coding system published by the American Medical Association that is used to report procedures and services performed during outpatient and physician office encounters


3.02 Medical Insurance Key Terms p age 2

CMS Center for Medicare and Medicaid Services – administrative agency within the federal Department of Health and Human Services; responsible for the operation of Medicare and Medicaid

explanation of benefits (EOB)

report detailing the results of processing a claim (Ex: payer reimburses provider $80 on a submitted charge of $100)

health insurance claim form (CMS-1500)

documentation submitted to a third-party payer or government program requesting reimbursement for healthcare services provided

medical necessity linking every procedure or service code reported on the claim to an ICD-9-CM condition code that justifies the necessity for performing that procedure or service

preauthorization prior approval for treatment by specialists and documentation of post-treatment reports

remittance advice notice sent by the insurance company that contains payment information about a claim


3.02 Case Study – Name___________________ Insurance Claim Forms Completion Date ____________________

Handout

Complete a CMS-1500 claim form for each patient using their patient information form, copies of their insurance cards, charts and ledger cards. Use the information on the Patient Registration Form Handout and Documentation on Patient’s Medical Record to complete the claims for patients in a general surgeon’s office and family practice. Physician Information Group: Family Medicine and General Surgery Specialist, PA

2222 Staton Road Anyville, NC 27834

Federal Tax ID #: 56-412250 Physicians & Physician Insurance (PIN)#: S. W. Jones, MD Medicaid #: 8974585

Medicare #: 21022A B. D. Thomas, MD Medicaid #: 8921333

Medicare #: 22552A Hospital: Generic Hospital

P.O. Box 6028 Anyville, NC 27000-6028

Insurance programs that the office participates in are Medicare, Medicaid, BCBS.

3.02 Patient Registration Form Name ___________________ Handout Date _____ _______________

Name: Jean Smith

Social Security No: 244-44-4444

Street Address: 452 Farm Blvd

City, State, Zip: Anyville, NC 27828

DOB: 1-5-40

Phone: (H) (252) 753-5300 (W): (252) 753-5266

Sex: Female

Occupation/Employer: Perdue

Physician: Jones

Spouse’s Name: John Smith

Status: Married

Emergency Contact: Jane Smith

(Other than Spouse)

Emergency Contact Phone: 753-1111

Insurance Plan:

Prudential

Policy ID#:

YPP5689XX3

Group #:

37500

Secondary

Policy:

Policy #:

Group #:

Policyholder Name:

Amanda Dixon

Birthdate:

1-5-40

Relationship:

Self

Policyholder

Name:

Birthdate:

Relationship:

Assignment of Insurance Benefits

I hereby authorize direct payment of surgical/medical benefits to Dr. ___________________ for services rendered by

him/her in person or under his/her supervision. I understand that I am financially responsible for any balance not covered

by my insurance.

Authorization to Release Information

I hereby authorize Dr. ________________________ to release any medical or incidental information that may be necessary

for either medical care or in processing applications for financial benefit.

Medicare-Medicaid

I certify that the information given by me in applying for payment is correct. I authorize release of all records on request. I

request that payment of authorized benefits be made on my behalf.

A photocopy of these assignments shall be valid as the original.

PATIENT SIGNATURE: Amanda Dixon DATE: 01-01-06

PARENT/GUARDIAN (please print): _____________________________SIGNATURE: _________________________

3.02 Documentation on Patient’s Medical Record Name ___________________ Handout Date __________ __________

Date

Jean Smith Account # 4XXX HISTORY & PHYSICAL

10-15-07

10-16-07

11-4-07

11-5-07

Patient still having abnormal bleeding with the flow getting heavier each month. LMP

10-1-07, lasting 6 days, heavy with large clots. Heavy periods for the past year with

increased pain and clots. Hemoglobin on last visit was 11.2

Uterus soft with fibroid uteri. Uterus increased in size. Also has cystourethrocele

without a uterine prolapse.

Hemoglobin 9.0.

Menorrhagia, severe.

Anemia.

Fibroids, leiomyomata uteri.

Cystourethrocele without uterine prolapse.

Schedule TAH-BSO, Marshall-Marchetti in 2 weeks.

S. w. Jones, MD

Scheduled TAH-BSO, Marshall-Marchetti for 11-4-07. LT/RN

Performed total abdominal hysterectomy with bilateral salpingo-oophorectomy with

Marshall-Marchetti for the cystourethrocele.

S. W. Jones, MD

Patient discharged from the hospital to return to the office in three weeks for a recheck.

S. W. Jones, MD

3.02 Filing Records Name _______________ Handout Date ________________ Alphabetic Filing

• All personal names are transposed so that the last name is the primary indexing unit, first name second and middle name or initial is the third unit.

• April Smith Smith, April • Jesse W. Brown Brown, Jesse W. • If filing identical names, use the city and street names to place in alphabetical

sequence • Don S. Clay, Asheboro, N. C. Clay, Don S. Asheboro • Don S. Clay, Raleigh , N. C. Clay, Don S. Raleigh

• Names with prefixes are filed disregarding punctuation and spacing within the surname • Rena de la Santos de la Santos, Rena • Amee La Croix La Crois, Amee • David M. McArthur McArthur, David M.

• Abbreviated names are files as though the names were spelled out. • Chas. Malley Malley, Charles • Charles L. Malley Malley, Charles L.

• Professional titles and degrees are placed at the end of the name and enclosed in parentheses.

• Organizations and Businesses in order they are written American, Red, Cross

• Exception: If Owner's name is name of business, then follow name rules The T.S. Eliot Company is filed as Eliot, T., S., Company

• Hyphenated names are considered as one unit • After indexing, follow strict alphabetical order, use as many letters as needed to

file • Nothing comes before something • Numbers in a name are indexed as though they were spelled out

Numeric Filing

• Cross indexing (referencing) is required • Patient names are indexed as for alpha filing • Agency numbering usually runs in order, and a record is kept of which numbers

have been assigned. • When patient comes to agency, alpha cross index is checked to locate patient's

file number • Numbers go in order from small to large • If zero falls before other numbers, the zero is disregarded when filing • Many systems use the same terminal (last) digit for certain shelves or drawers -

if so - check the last digit and then put all the same last digits together

3.02 Alphabetic Filing Name __________________ _ Handout Date ____________________ Directions: Index each patient’s name in the space provided. Put the names in alphabetic order in the space provided.

Indexed Names Alphabetic Names

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Mary Childers Johanna Q. Miller Rev. Frank A. Mathews Sr. Dollar Tree, La Grange, N. C. Francis Haddock Dollar Tree, La Grange, Il. Daniel L. Bach South-West Auto Club Susan B. Jordan, CPA Jerri B. Evans William Morris, Jr. Dollar Tree, La Grange, Ky. Southwest Regional Airport Hans Bradshaw Dr. Frank A. Mathews, Jr.

3.02 Alphabetic Filing Name __________________ _ Handout KEY Date ____________________ Directions: Index each patient’s name in the space provided. Put the names in alphabetic order in the space provided.

Indexed Names Alphabetic Names

Childers, Mary 1 Bach, Daniel L. Miller, Johanna Q. 2 Bradshaw, Hans Mathews, Frank A. (Rev.) 3 Childers, Mary Dollar Tree, La Grange, N. C. 4 Evans, Jerri B. Haddock, Francis 5 Haddock, Francis Dollar Tree, La Grange, Il. 6 Jordan, Susan B. (CPA) Bach, Daniel L. 7 Dollar Tree, La Grange, Il. South-West Auto Club 8 Dollar Tree, La Grange, Ky. Jordan, Susan B. (CPA) 9 Dollar Tree, La Grange, N. C. Evans, Jerri B. 10 Mathews, Frank A. Jr. Morris, William Jr. 11 Mathews, Frank A. (Rev.) Dollar Tree, La Grange, Ky. 12 Miller, Johanna Q. Southwest Regional Airport 13 Morris, William Jr. Bradshaw, Hans 14 South-West Auto Club Mathews, Frank A. Jr. 15 Southwest Regional Airport

1. Mary Childers 2. Johanna Q. Miller 3. Rev. Frank A. Mathews Sr. 4. Dollar Tree, La Grange, N. C. 5. Francis Haddock 6. Dollar Tree, La Grange, Il. 7. Daniel L. Bach 8. South-West Auto Club 9. Susan B. Jordan, CPA 10. Jerri B. Evans 11. William Morris, Jr. 12. Dollar Tree, La Grange, Ky. 13. Southwest Regional Airport 14. Hans Bradshaw 15. Dr. Frank A. Mathews, Jr.


3.02 Numeric Filing Name ___________________ Handout Date ____________________ Directions: Place each group of numbers according to the numeric filing system in the space provided.

Straight Numeric Terminal Numeric

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

1. 09248-97 2. 94009-98 3. 02736-91 4. 19985-98 5. 84755-98 6. 35594-99 7. 93747-92 8. 83790-99 9. 76630-96 10. 66655-96 11. 02836-91 12. 83610-99 13. 87330-91 14. 73660-97 15. 71740-92


3.02 Numeric Filing Name ___________________ Handout KEY Date ____________________ Directions: Place each group of numbers according to the numeric filing system in the space provided.

Straight Numeric Terminal Numeric 02736-91 1 02736-91

02836-91 2 02836-91

09248-97 3 87330-91

19985-98 4 71740-92

35594-99 5 93747-92

66655-96 6 66655-96

71740-92 7 76630-96

73660-97 8 09248-97

76630-96 9 73660-97

83610-99 10 19985-98

83790-99 11 84755-98

84755-98 12 94009-98

87330-91 13 35594-99

93747-92 14 83610-99

94009-98 15 83790-99

1. 09248-97 2. 94009-98 3. 02736-91 4. 19985-98 5. 84755-98 6. 35594-99 7. 93747-92 8. 83790-99 9. 76630-96 10. 66655-96 11. 02836-91 12. 83610-99 13. 87330-91 14. 73660-97 15. 71740-92


3.02 Telephone Etiquette Name ______________ Handout Date _______________ Answering the phone

1. Speak clearly.

2. Use your normal tone of voice.

3. Use proper language.

4. Address the caller by his/her title (Good morning Mr. Doe.)

5. Listen to the caller and what they have to say. Repeat information if you are taking a message to verify accuracy.

6. Be patient and helpful.

7. Always ask politely if you need to put someone on hold.

8. Always focus on the call. Try not to get distracted by others.

9. Do not eat or drink when talking on the phone.

Placing a call

1. Always identify yourself.

a. Name

b. Company name

c. Phone number

2. Always be aware of confidential information.

3. Always be aware of people around you. Be discreet.

4. Avoid leaving long messages. Keep it brief.


3.02 Answering the Telephone Teacher Resource Explain to students that they are answering the phone at South Hills Healthcare, P. A. This is the office of Dr. Margaret Pelly and Dr. Angela Grant. Dr. Pelly is with a patient who is having a routine follow-up for chronic hypertension. Dr. Grant is out of the office this afternoon. 1. A new nurse called from the newborn nursery to report that one of the babies has

a rash.

2. Dr. Pelly’s 14 year old daughter is calling from school because she has a really bad stomach ache.

3. A patient needs to have a prescription for pain medicine refilled. He has a

migraine, and has run out of medication. The patient is the husband of a pediatrician in town.

4. Dr. French is calling Dr. Pelly about joining the practice. Dr. French is persistent

about getting to speak with Dr. Pelly. 5. The mother of a young boy was told that Dr. Pelly would call in medication for her

son’s earache. The mother is very upset because when she got to the pharmacy, they had no record of the medication being called. Now she has to wait and her son is crying and pulling at his ear.

6. Mrs. Tommy Hooks has just moved to town and is looking for a family doctor to

take care of her family. She asks lots of questions, like how long does it usually take to get an appointment, does Dr. Grant see her patients on time, etc. During this time, Mrs. Smith is waiting to check out.

7. Gracie called but was put on “Hold” for 15 minutes. When you return to her line, she is very upset. Her father is holding his chest and looks pale.

8. A drug company sales representative is calling to talk to Dr. Pelly. If asked to leave a message, ask a few questions about when the doctor will see her last patient and if she usually sees drug representatives at the end of the day. Finally, leave a message.

9. The nursing assistant called from the nursing home. Mr. Green is not cooperating,

will not get out of bed and seems confused. There are frequent calls about Mr. Green.

10. A 110 pound, elderly woman spilled a pot of boiling water down the front of her dress. The dress adhered to her legs and the skin came off when she removed the dress fabric. She called 911 and they are bringing her into the office. The EMTs covered the burns with cold, wet compresses.


3.02 Scheduling Appointments Teacher Resource Correct scheduling of appointments is essential for good public relations. Computerized systems specific to agency will be learned on the job. Appointment Procedures • Vary from office to office • Computer Scheduling

• Computer automatically locates next available appointment • Provides a record of appointments already scheduled • Prints out copies of daily schedule

• Appointment book • Time blocked in 15-minute intervals • First…block out lunch, meetings, etc. with a large X • Appointment time depends on purpose of appointment and would be determined by

the agency • Some agencies use buffer period When a patient calls… 1. Find out reason for call 2. Try to schedule convenient appointment for patient 3. Try to give choices 4. Be sure you have the required information before closing the call 5. Spell names correctly (ask if you don't know) 6. Write the patient's phone number in the appointment ledger 7. Repeat the date, time and important appointment details 8. Thank the caller and say good-bye 9. Double-check appointment book to assure correct time was blocked off If the patient calls to cancel… 1. Ask if he/she would like to reschedule 2. Erase/delete appointment and reschedule 3. Do not ask why they are canceling Scheduling issues… 1. In many agencies, patients who don't show up are billed 2. "No show" noted on patient's chart 3. If an emergency occurs and the health care provider is called away, sometimes all

appointments must be canceled 4. Sometimes, offices will make time for patients with emergencies to be seen


3.02 Maintain accounting records Teacher Resourc e

What is the purpose of financial records? Used to record and analyze the financial performance of a business.

What are financial statements? Reports that sum up the financial performance of a business.

Asset records name the buildings and equipment owned by the business, original and current value, and the amount owed if money was borrowed to purchase the assets.

Depreciation records identify the amount assets have decreased in value due to their age and use.

Inventory records identify the type and number of products on hand for sale/use.

Records of accounts identify all purchases and sales made using credit. An accounts payable record identifies the companies from which credit purchases were made and the amount purchased, paid, and owed. An accounts receivable record identifies customers that made purchases using credit and the status of each account.

Cash records list all cash received and spent by the business.

Payroll records contain information on all employees of the company, their compensation, and benefits.

Tax records show all taxes collected, owed and paid. As a part of payroll, employers must withhold a certain percentage of employees’ salaries and wages for federal income tax. The company also makes payments for Social Security and Medicare and, in some cases, for unemployment compensation.


3.02 Sample Budget Teacher Resource

South Hills Healthcare, P. A. 123 American Boulevard,

Anytown, North Carolina 99999

Budget Actual Difference

Total Income $4,575,761.00 $3,303,137.00 $1,272,624.00

Expenses

Employee Salaries $2,355,182.00 $2,358,346.00 Drug supplies $17,473.00 $27,272.00 Medical and Surgical Supplies

$64,768.00 $67,195.00

Pathology $6,716.00 $8,716.00 Food Supplies $57,866.00 $53,828.00 Domestic Services $49,766.00 $50,969.00 Fuel, Light, Power, and Water

$67,245.00 $89,235.00

Insurance $68,849.00 $68,849.00 Motor Vehicle Expenses

$28,114.00 $26,235.00

Repairs and Maintenance

$38,334.00 $30,103.00

Maintenance Contracts

$34,023.00 $34,023.00

Patient Transport $1,632.00 $1,632.00 Other Administrative Expenses

$211,746.00 $167,339.00

Bad Debts $733.00 $1,733.00

Total Expenses $3,002,447.00 $2,985,475.00 $16,972.00

Net Income $16,795.00


3.02 Prototype Assessment Items Note: These items illustrate the types of items used in the item bank for this objective. All items have been written to match the cognitive process of the understand verb in the objective. Questions require students to interpret, summarize or explain responsibilities of health informatics personnel. These exact questions will not be used on the secured test, but questions in similar formats will be used. These assessment items may be used as prototypes by teachers and students to generate similar items to comprise formative assessments for you classroom. This strategy is especially helpful during the field test year when classroom item banks are not available. Results of formative assessment should be used to diagnose levels of mastery, determine if re-teaching is needed, and guide further instruction. 1. After reviewing a patient chart completed by a dental hygienist, the health

insurance specialist assigns CPT codes to: a. charges for treatment. b. diagnoses of cavity in left molar. c. procedures for cleaning and fluoride treatment. d. supplies for cleaning.

2. The health informatics professional who compiles statistical information from

patient records has the career responsibility to: a. analyze information. b. abstract and code patient information. c. document information. d. manage the health information system.

Documents

Management Duties 1 Informatics 2 1 4 ICD -9-CM …images.pcmac.org/.../3.02_Understand_health_informatics_worksheets.pdfmedical terminology 3-Apply information for regulatory and