Healthcare Terminology and Concepts, Exams of Nursing

Download Healthcare Terminology and Concepts and more Exams Nursing in PDF only on Docsity! CIRCUMSTANTIAL-CCMC CCM Study Guide Questions and Answers. Who is eligible for WIC? - \Women, infants, children What does WIC provide? - \Vouchers for food, infant cereal, baby food,veggies, etc Utilization Review - \Evaluates appropriateness of an admission to a health care facility or extension of stay; also measures efficiency What is the CAGE acronym stand for and when is it used? - \Screens for alcoholism 1. Have you felt the need to CUT down on drinking? 2. Have ppl ANNOYED you by criticizing your drinking? 3. Have you felt GUILTY about drinking? 4. Have you felt the need for a drink in the AM (EYE Opener) Who does hospice serve? - \Both patient and family What is the Medicare criteria for hospice and which Part covers it? What will Medicare NOT cover? - \<6 month life expectancy -Part A -Not cover treatment to cure illness, room and board $0 OOP cost for hospice What is the O2 sat level for Medicare to approve home O2? - \88% or less to approve home O2 at rest/awake 88% or less x5 min while asleep custodial care - \Bathing, eating, dressing Family typically covers it SSDI (Social Security Disability Income) - \Means of income for an individual who are restricted in their ability to work due to a disability (usually physical); total disability (not short term);available to workers who have accumulated a sufficient number of work credits -must be younger than 65 -5 month waiting period -SSDI is funded by the Social Security taxes paid by workers, employers and self- employed people POS (Point of Service) - \Allows individual to choose provider Higher cost in premiums, deductibles and coinsurance Primary HIV infection prevention - \reduction of transmission and acquisition of HIV secondary HIV infection prevention - \prevent a person with HIV from becoming ill or dying What does the Rancho Los Amigos scale measure? - \Assess individuals after a closed head injury, such as traumatic brain injury (TBI), based on cognitive and behavioural presentations as they emerge from COMA I = no response to all stimuli III = localized response (specific not inconsistent) V = confused/inappropriate VIII = purposeful, appropriate, A&O x4 Delerium - \- Disturbance of conciousness; reduced ability to focus, sustain or shift attention; change in cognition - Develops over hours or days and fluctuates during the course of the day Dementia - \Overall decline in intellectual function, including language difficulty, simple calculations, planning, judgement, motor skills privileged communication - \legal term for a right that belongs to a client Medicare requirement prior to SNF admission - \3 day hospital stay is required Wellness coach per-requisites - \- Can open own business w/minimal training - For health care employers: generally a Bachelor's degree is required Examples of community based programs - \Church grief support, ESL tutoring, social organizations mental capacity - \A person's "ability" or "capacity" Describes a cluster of mental skills people use in their everyday lives DSM-IV - \The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard classification of mental disorders used by mental health professionals Palliative Care Program - \Specialized care for people with serious illnesses. Provides pt with relief from the symptoms and stress of a serious illness Goal is to improve quality of life for both the patient and the family. Process of continual assessment of pt's needs and their treatment option inline with their values and beliefs. What is not protected or covered under the ADA? - \If Rx controls the disability Clinical symptoms related to illegal drug use, drinking at work or criminal pathologies like kleptomania or pyromania ADA - \civil rights law that prohibits discrimination against individuals with disabilities in all areas of public life, including jobs, schools, transportation, and all public and private places that are open to the general public ADA's definition of disability - \a physical or mental impairment that substantially limits a person's ability in one or more major life activities Which Axis' in DSM V ARE frequently covered by the ADA? - \Axis I - list mood, anxiety, and psychotic disorders like PTDS Axis II - maladaptive personality disorder than can lead to distress of oneself like paranoia or anti-social Life planner - \Develops a Life care plan; Help pts who have suffered catastrophic injuries and illnesses, advocate for them, and plan out their care Part of a legal team in medical malpractice/personal injury case; also active in worker's comp Can be RN, rhab RN, SW, PT, etc life plan - \A document based on EBP and assessment/research; provides a plan for furture and current needs with associated costs for pts with catastrophic injury or chronic illness CARF (commision on accreditation of rehab facilities) - \Private, nonprofit organization that establishes standards of quality of services to ppl w/disabilities Offers voluntary accreditation for rehab facilities and et of nat'lly recognized standards Medicare Part A - \Hospitalization Medicare Part C - \Offered by private insurers, "Medicare Advantage" plans Medicare Part B - \Voluntary Program, covers outpatient services, physician services, ER visits Medicare Part D - \Rx coverage Examples of employers that are exempt from the ADA - \Employers with fewer than 15 employees, federal gov't, Native American tribes, religious or private membership organizations When is a life plan used? - \In a court system as groundwork for settlement of a claim for personal injury or medical liability National Committee on Quality Assurance (NCQA) - \Evaluates quality of care provided by healthcare organizations and managed care organizations; they set predetermined standards of care 5 ETHICAL principles of CM - \1. Beneficence (do good) 2. Non malfeasance (do no harm) 3. Veracity (truth, honesty) 4. Justice (equality of treatment) 5. Pt autonomy (freedom to choose) tort - \Injury, damage or wrongful act done WILLFULLY or negligently What are 3 common dilemmas of CM? - \1. Focus of advocacy (CM conflict between best interest of pt, pt fam, payer and society) 2. Supremacy of values (clash of values of CM, CM employer, pt, family or insurer) 3. Conflict of Duties (carry out wishes of client may cause harm to others--ex: HIV+ pt confidentiality to others) Important points for release of AIDS/HIV info - \-Varies by state -Each state requires a signed form -if written permission is NOT obtained in states w/requirements for a form, ALL references to HIV status must be deleted, including test, and the results When can client confidentiality be broken? - \1. Intent to harm 2. Emergency services 3. Protect from self harm 4. Notify authorities of abuse, neglect 5. Mandated reporting by public health laws 6. Court order/subpoena 7. Payment for services 8. Professional consultation What 3 areas can CM make an impact on ergonomics in the workplace? - \1. IDENTIFY illness, injury that's occurred on the job and report them 2. REFERRALS for endurance training, retrain vocational assessment (job environment) 3. ADVOCATE for worker to make employer aware of limitations respite care - \psychological and physical support provided to caregivers (ex: support group, away camp for a child re: specific diagnosis) fiduciary - \One person acts in another person's best interest What is informed consent and what should it include? - \Pt's right to determine what will be done to his/her body -explain tx, expected results, risks and discomforts, benefits, alternatives to achieve desired results, medical consequences without any tx at all What is the purpose of job function analysis? - \0-documents requirements of job and work performed -acts as basis for LATER improvements (eg, describing a job training needs, performance) modified job - \-change in regular job duties d/t injury or illness -temp basis--given sick employee time to regain to normal condition SSI (Supplemental Security Income) - \-pays benefits to low-income people who are 65 or older; to adults who are disabled or blind; children who are disabled and blind -financed by general revenues that the Treasury Department collects to run the U.S. government -do NOT need to be receiving social security benefits capitation - \Show success or failure or treatment and data to reduce length of stay or exploring alternative care plans; conducted during an inpatient stay or services already in progress retrospective reviews - \Allows Cm to support their role in tx plan and provides valuable info in planning FUTURE/similar cases 5 barriers of communication - \1. physical interference 2. psychological noise 3. Info overload 4. Perception barrier (culture, education) 5. Structural barrier (bureaucracy) BATNA - \"Best Alternative to Negotiated agreement" successful negotiation factors - \trust, information, focus on pt, respect, timely communication, active listening distributive justice - \Moral basis for dissemination of goods and evils, burden/benefits, especially when making decisions regarding allocation of health care resources How long do symptoms of major depression for diagnosis have to be present? - \Depressed mood or loss of interest for at least 2 weeks What is the expected outcome of workman's comp? - \Facilitate the eventual return of injured worker to gainful employment viatical settlement - \Selling of one's life in insurance policy to a 3rd party before one's death. Policy holder benefits rather than beneficiaries. Usually sold 40-90% face value depending on life expectancy (< time = > $) reasonable accommodation - \Any change in work environment or in the way a job is performed that enables a person w/disability to enjoy equal employment -Employer except if cost causes undue hardships ombudsman - \Mediator Person assigned that mediates fair settlements especially between aggrieved parties Emergency Medical Treatment & Labor Act (EMTALA) - \"Anti Dumping Law" Federal law requires any pt that comes to the ED is to be stabilized and treated regardless of insurance status or ability to pay Reverse Mortgage - \Converts part of equality in their home for cash Lender makes payment to borrower Borrower not required to pay back loan until sold or vacated Borrower still pays utilities and taxes for 62 y/o + Difference between Disability vs Impairment vs Handicap - \Disability- restriction or lack of ability to PERFORM an ACTIVITY in the manner/WNL for a human (ex: for CP, inability to walk) Handicap - \Handicap-DISADVANTAGE given to an individual that limits or prevents fulfillment of a ROLE that is normal (ex: CP prevents person from fulfilling normal role at home, like sports activities his age considered normal) Impairment - \loss, abnormality of psychological, physical STRUCTURE or Function (ex: CP, inability to move legs easily at joints) methadone - \heroin or morphine like drugs; also also be given for meth addicts barbiturates - \Cause CNS depression Used as sedatives, anxiolytics, anticonvulsants and tx insomnia What are the 3 areas to determine functional status of a patient? - \1. ADLS (dress, bathe, feed, toilet) 2. IADLS (shopping, prep meals, house work) 3. Environmental factors or barriers (stairs, w/c) functional capacity exam - \Assess physical and functional ABILITY to perform a task What is carpal tunnel syndrome and its symptoms? - \Median nerve becomes compressed at the wrist s/s: numbness, tingling usually in the thumb, index and middle finger; burning pain, tend to occur at night and lying down risk management - \Clinical and administrative activities to identify, evaluate and reduce risk of injury to pt, staff and visitors; can be proactive (avoid/prevent) or reactive (minimize loss or damage) Are drug screening during hiring process covered by ADA? - \Tests for illegal during use are NOT covered by ADA medical home model of care - \AKA patient centered medical home = provider team focus on pt needs (nutritionist, RN, pharmacists) Designed around pt needs; aims to improve access to health care services (eg. email, extended hours) SF-36 - \Health survey used by some CM; 36 questions yeilds 8 scale profile of functional wellbeing scores Res ipsa loquitor - \"The thing speaks for itself" shift burden of proof upon the defendant to prove it was not d/t his/her negligence What is subrogation? - \Right to pursue and lieu upon claims for medical charges against another person (or entity) viatical settlements - \1. Sell life insurance for 50-80% of face value 2. If you live longer than life expectancy, NOTHING happens to viaticus 3. Mbr must have a life threatening illness and a life ins. policy for about 2 years (EX: AIDS, Alzheimer, heart disease) 4. Look for a company that has a 15 day rescission period 5. $ sent through wire transfer or company check Types of Advance directives - \Living Will - spells out tx you would/wouldn't use to keep you alive DPOA (aka Health care proxy)- name person to make decisions for you when you've been unable to do so For Worker's comp, what is allowed regarding changing MDs? - \The injured worker may change provider once without insurer approval and with insurer approval afterward What are the 6 steps of fitting a trans tibial BKA prosthesis? - \1. Cast of stump = push on soft prominences and avoid bone ones 2. Model of boney prominence so weight will be transferred ERISA- Employee Retirement Income Security Act applied companies with how many employees? - \(pension plan) 100+ employees FMLA applied companies with how many employees? - \50+ employees COBRA applied companies with how many employees? - \20+ employees Longshore and Harbor Workers' Compensation Act (LHWCA) - \compensation and medical care to employees disabled from injuries that occur on the navigable waters of the United States or in adjoining areas used in loading, unloading, repairing or building a vessel. Survivor benefits also are provided if injury causes includes workers employed in maritime occupations The Federal Employees' Compensation Act - \The United States shall pay compensation coverage to three million Federal and Postal workers including wage replacement, medical rehabilitation benefits for work-related injury and occupational disease. FECA is a highly cost-effective self-insurance system. Railroad Workers Act - \The RLA was the first federal law guaranteeing the right of workers to organize and join unions and elect representatives without employer coercion or interference. applies to freight and commuter railroads, airlines, companies directly or indirectly controlled by carriers who perform services related to transportation CHIP Children's Health Insurance Program - \serves uninsured children up to age 19 in families with incomes too high to qualify them for Medicaid. States have broad discretion in setting their income eligibility standards, and eligibility varies across states Medicaid - \health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities. Medicaid is administered by states, according to federal requirements. The program is funded jointly by states and the federal government. Title XIX of the Social Security Act - \Medicaid was signed into law in 1965 along side Medicare Retiree insurance with medicare - \if you're retired and have Medicare and group health plan (retiree) coverage from a former employer, generally, Medicare pays FIRST (primary) for your health care bills and your group health plan coverage pays second Medicare Advantage plan - \variety of private health plans — most often HMOs and PPOs — that Medicare offers as a coverage alternative to the traditional program (Medicare Parts a & B). Most charge a monthly premium in addition to the Part B premium. All plans, by law, have annual limits on out-of-pocket costs Black Lung Benefits Act - \provides monthly payments and medical benefits to coal miners totally disabled from pneumoconiosis (black lung disease) arising from employment in or around the nation's coal mines. 3 Types of O2 delivery devices - \Gas, liquid or oxygen conentrator Gas oxygen - \The gas form of oxygen is put into variously sized cylinders or tanks. The cylinders or oxygen tanks contain compressed oxygen. The cylinder is equipped with a regulator that controls the flow rate. Because the flow of oxygen out of the cylinder is constant, an oxygen conserving device may be attached to the system to avoid waste. This device releases the gas only when you inhale and cuts it off when you exhale. Oxygen can be provided in a small cylinder that can be carried with you. Large tanks are heavy and are only for stationary use liquid oxygen - \When released, the liquid converts to a gas and you breathe it in just like the compressed gas. This storage method takes up less space than the compressed gas cylinder, and you can transfer the liquid to a small, portable vessel at home. Liquid oxygen is more expensive than the compressed gas. Liquid oxygen is very cold, around 297° below zero Oxygen concentrator - \his medical device filters oxygen from room air and gives almost 100% oxygen to the patient. Oxygen concentrators are powered by electricity.It does not need to be resupplied. It is not as costly as liquid oxygen. Extra tubing permits the user to move around easier. Medicare coverage for oxygen - \Part B You pay 20% of the Medicare-approved amount. Medicare pays suppliers a monthly fee for providing all medically necessary oxygen and oxygen equipment, including accessories like tubing or a mouthpiece. After 36 months of continuous use, Medicare stops making rental payments for the oxygen equipment and accessories, but, in almost all circumstances, you'll continue to get the oxygen, oxygen equipment, and accessories from the same supplier with no rental charge until the end of the reasonable useful lifetime of the oxygen equipment (generally 5 years after the date that the equipment was delivered to you) 80/20 rule Pareto Principle - \80 percent of the land in England (and every country he subsequently studied) was owned by 20 percent of the population; the relationship between input and output is rarely, if ever, balanced Prospective Review - \Review need for CM prior to start of service (pre-admission review); determines necessity and length of stay; 3-5% cases reviewed prospectively need CM Concurrent Reivew - \Review while services are being referred and success/failures of tx; provides data for reducing length of stay and explore alternate care plans Retrospective Reivew - \Outcomes after PT discharge; tracks appropriateness of care and consumption of resources; assist w/planning future, similar cases. Patient's bill of rights 1973 - \Right to privacy, receive info on dx and tx, to make own decisions and to refuse tx, advance directives, consent or decline to participate in research Indemnity - \Money paid as wage replacement when the injured worker is determined medically unfit to work Three point contact - \Employer, injured worker, treating physician Medical home care - \Delivery of primary care; patient centered and patient learning and organized to their own care at any level they choose. Coordinated care. Available 24/7 HCAHPS - \Hospital consumer assessment of healthcare providers and systems. Standardized survey to measure patient's hospital care 8 essential activities with direct client contact - \Assessment, planning, implementation, coordination, monitoring, evaluation, outcomes, general (activities/interventions) \A civil wrong for which a private individual may recover money damages, stiffening from a breach of duty created by law Paternalism - \Relationship between doctors and patients Patient sovereignty model - \The patient is "boss" Dual relationship - \Bring both friend and CM, which can lead to conflict of interest Gag clause - \Prevents healthcare providers from discussing with patient treatment options not covered by that particular health plan Surrogate for pt w/no living parent,spouse, sibling, SO or friend - \2 physicians Exception to written consent - \Oral consent, emergency tx and patient unable to sign, to dwtermine cause of death, research purposes in which pt is anonymous Quality review - \Determine if patient received recognized standards of care Needs of pt in an assisted living/custodial care - \Consistent regimen of PO meds but does not need suctioning Needs of PT in SNF - \Complex but generally stable PT who may need central line care, IV push medications, variable adjustments in dosages of meds and assessment of lab values Per diem rate - \Fixed daily dollar amount Cost based reimbursement - \Actual cost of patients care Fee for service - \Provider bills insurance co. And co. Pays for service Capitation - \Fixed monthly payment paid to provider in advance of services Dysphagia - \Difficulty swallowing Dysphasia - \Absence of language function Hospice is for what type of patients - \Any terminal condition Clinical pathways - \Help standardize care for a particular diagnosis. Pathways are multidisciplinary in nature Example of focus of advocacy - \PT w/terminal CA needs expensive tx but at end of ins. Coverage and family has no financial resources Conflict of duties - \CM causes harm to others while carrying out client's wishes Supremacy of values - \Determining whether values of a PT, family, CM, or insurer should take precendexe Change-agent illness - \Illness or injury that changes a person's life Examples of ancillary service - \Services needed by a PT in addition to nursing and medicine; Ex: PT, OT, nutrition, radiology, lab services Delivery of baby: Length of hospital stay is determined by - \Starting at time of admission if delivery is outside of hospital. If delivery inside hospital, starts at time of delivery; for multiple births: begins at time last infant is born Early periodic screening, diagnosis, and treatment (EPSDT) - \Exams are for children Continued stay review - \Occurs at specific intervals during hospital stay Stop loss - \Aka reinsurance. Insurance bought by an insurance company to protect itself from highly expensive cases. There are some dx statistically proven to be extremely expensive, such as organ transplant and AIDs Concurrent procedural terminology (CPT) - \Numeric code that describes a dx, medical or surgical service (ex: 99xxx). Gives uniform info about services. ICD-10 - \Codes are alphanumeric destinations that represent disease or condition (785.2) Upcoding - \When a billing code makes a PT more severlt I'll than he really is Right of subrogation - \Allows insurance plans to pay for initial treatment until payor responsibility is ascertained Coordination of benefits - \Lets payors decrease payments by amount of coverage provided by another medical insurance policy Indemnity - \Form of commercial medical insurance whereby patient pays a deductible and percentage of costs Tricare prime - \military HMO option. Does not cover all health care procedures; some require preauthorizations Tricare Extra - \military PPO option Tricare standard - \military Fee for service option Civilian health and medical program of veterans affairs - \Law allowing medical benefits to survives and dependents of veterans who are permanently and completely disabled w/a service related condition. Not part of tricare. Coverage stops when person is eligible for Medicare Stark law - \Prevents physicians receiving kickbacks for referral and consultations Orthotics - \Applied externally to a part of body to support, align or improve movement Outcome research yields excellence - \Requires hospitals to collect data and transmit them to Joint commission for minimum of 4 core measures to evaluate performance data for accreditation Catastrophic cases - \medical claims of high dollar amounts Network model - \type of health plan that contracts with numerous groups of physicians Health Care Financing Administration (HCFA) - \monitors all health plans providing care to Medicare/Medicaid beneficiaries; measures improvement and quality care National Association for Healthcare Quality (NAHQ) - \organization for healthcare quality management progessionals Return on Investment (ROI) - \(benefits-costs)/costs x 100 = % ROI profit or loss that result from a hospital's investment in CM CM Dashboard - \management reporting system providing executive summary level reports of the program (similar to a report card) fact witness - \supplies information about things seen or heard expert witness - \supply specialized information such as clarifying procedures and processes; must be impartial Rolfing - \stretches fascia to release adhesions and relieve muscle and joint restriction Reiki - \laying on of the hands to improve the flow of "life force energy" to bring about healing Upledger's approach - \form of caniosacral therapy that relieves restriction in the meningeal fascia Suicide intent - \demonstrated by giving away possessions or by performing other life-closing actions suicidal ideation - \thoughts about killing oneself suicidal plan - \contemplated ways he could kill himself suicidal gesture - \attempt to cause self-injury without actually intending to commit suicide Karnofsky scale - \classifies a pt functional impairment; assess prognosis of pts; lower the score, the worse the prognosis case closure domain of CM - \ending the CM-client relationship and on notification of service termination to stakeholders integrated delivery system - \hospitals, physicians, and other providers to managed care; provides services along continuum of care allopathic medicine - \conventional Western medicine Partial hospitalization - \pt spends at least 4 hours daily in a structured setting receiving psychotherapy and milieu therapy temporary partial disability - \impairment that prevents a worker from returning to his usual job but allows him to work in some capacity until the injury is healed temporary total disability - \impairment that renders a worker unable to work in any capacity but carries the expectation of recovery and return to normal employment permanent partial disability - \an impairment or injury that results in decrease in a worker's wage-earning capacity treatment protocols - \address specific treatments for a given clinical problem and allow providers some flexibility in selecting x options; less specific than algorithms All payer system - \payers (whether individuals, companies or govt) of healthcare bills pay the same rates for the same medical service; rates are set by the govt Beneficiary liability - \amount the beneficiary is responsible for paying to a provider for Medicare covered services (can be a form of co payment, deductible or balance billing) Composite rate - \bundle of services needed and is paid by Medicare (ex: meds, tests, supplies needed for dialysis) Job lock - \pt faces a predicament when he wants to change jobs but faces losing crucial healthcare benefits if he does Lag days - \inappropriate acute inpatient days that occur when a pt should have been DC'd sooner than she actuallywas Life Care Plan - \consistent, holistic, elder-centered approach to the practice of law that helps families respond to every challenge caused by chronic illness or disability (catastrophic injury) of an elderly loved one half life - \period of time required for the concentration or amount of drug in the body to be reduced by one-half--how long it takes the body to get rid of half the dose Birthday Rule - \primary health insurance plan is the one that belongs to the parent whose birthday comes up first in the calendar year. It makes no difference to the insurance companies which parent is older; it's the pecking order of the month of the birthdays, and not the year of birth, that matters here 5 Principles of Vocational Rehab - \1. Respect for people w/disabilities 2. Respect for the privacy 3. inclusion, integration, and full participation 4. inclusion of a person's representative 5. individual advocacy, systemic advocacy, and community involvement. Sentinel Event - \unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. Dictionary of Occupational Titles (DOT) - \created by the Employment and Training Administration, and was last updated in 1991. Has been replaced by the O*NET Central to the project is the O*NET database, containing information on hundreds of standardized and occupation-specific descriptors OASIS - \Outcome and ASessment Information Set