Medical Terminology and Procedures, Exams of Nursing

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NHA CCMA PREP EXAM Questions with 100% correct Answers Latest Updates 2024 GRADE A+ Advance Beneficiary Notice (ABN) ✔✔A form provided to the patient when the provider believes Medicare will probably not pay for services received Allowed Amount ✔✔The maximum amount a third-party payer will pay for a particular procedure or service Copayment ✔✔a small fixed fee paid by the patient at the time of an office visit Coinsurance ✔✔a provision under which both the insured and the insurer share the covered losses, typically 80:20 deductible ✔✔specific amount of money a patient must pay out of pocket before the insurance carrier begins paying Explanation of Benefits ✔✔a form created by the insurance company to explain what charges were covered, denied, or need more documentation based on the claims submitted by the physician's office Participating provider (PAR) ✔✔Providers who agree to write off the difference between the amount charged by the provider and the approved fee established by the insurer Medicare ✔✔A federal program of health insurance for persons 65 years of age and older by Part A (hospitalization) or Part B (routine medical office visits) Tricare ✔✔U.S. government health insurance plan for all military personnel CHAMPVA ✔✔covers surviving spouses and dependent children of veterans who died as a result of service-related disabilities Medicaid ✔✔provides health insurance to the medically indigent population through a cost- sharing program between federal and state governments for those who meet specific eligibility criteria Managed Care ✔✔is an umbrella term for plans that provide health care in return for preset scheduled payments and coordinated care through a defined network of providers and hospitals CMS-1500 form ✔✔Standard insurance form used by all government and most commercial insurance payers. - 33 blocks - divided into three section CMS-1500 Section 1 ✔✔Carrier Block: contains the address of the insurance carrier and is located at the top of the form Sagittal Plane ✔✔divides body into left and right Coronal Plane ✔✔divides body into front and back Transverse Plane ✔✔horizontal division of the body into upper and lower portions Right Upper Quadrant (RUQ) ✔✔Right lobe of liver, gallbladder, right kidney, portions of stomach, small and large intestine Left Upper Quadrant (LUQ) ✔✔Left lobe of liver, stomach, pancreas, left kidney, spleen, portions of large intestine Right Lower Quadrant (RLQ) ✔✔cecum, appendix, right ovary and tube, right ureter, right spermatic cord Left Lower Quadrant (LLQ) ✔✔contains parts of the small and large intestines, left ovary, left fallopian tube, left ureter Epigastric Region ✔✔located above the stomach Umbilical Region ✔✔ hypogastric region ✔✔ Right Hypochondriac Region ✔✔right lateral region just below the ribs Left Hypochondriac Region ✔✔left upper region below the rib cartilage Right lumbar Region ✔✔right middle region near the waist Left Lumbar Region ✔✔ Right Iliac Region ✔✔ Left Iliac Region ✔✔ Chain of Infection ✔✔infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host Wheezing ✔✔Difficult breathing with a high-pitched whistling or sighing sound during expiration Rales ✔✔Crackles; wet crackling noise in lungs Rhonchi ✔✔loud rumbling sounds heard on auscultation of bronchi obstructed by sputum kg -> lbs ✔✔1 kg = 2.2 lbs Trendelenburg position ✔✔ Intradermal needle gauge ✔✔27-28 Intradermal Needle Length ✔✔3/8 in Subcutaneous Needle Gauge ✔✔25-26 Subcutaneous Needle Length ✔✔1/2 to 5/8 inch Intramuscular Needle gauge ✔✔20-23 Intramuscular Needle Length ✔✔1-3 inches Smaller ✔✔the higher the needle gauge number, the the diameter Precertification ✔✔A process required by some insurance carriers in which the provider must prove medical necessity before performing a procedure. EMR ✔✔electronic medical record suffix ✔✔word ending prefix ✔✔a syllable or word that comes before a root word to change its meaning Pancreas ✔✔digestion and endocrine Thymus ✔✔endocrine and immune Upcoding ✔✔A fraudulent practice in which provider services are billed for higher procedural codes than were actually performed, resulting in a higher payment. Usual Fee ✔✔Fee for a service or procedure that is charged by a provider for most patients under typical circumstances. Customary fee ✔✔fee typically charged for a service in a particular geographic area Reasonable Fee ✔✔The generally accepted fee a physician charges for an exceptionally difficult or complicated service. A charge is considered reasonable if it is deemed acceptable after peer review even if it does not meet the criteria for a customary fee or prevailing charges. Sanitization ✔✔removal of pathogens from objects to meet public health standards Sterilization ✔✔The process that completely destroys all microbial life, including spores. Disinfection ✔✔A process that eliminates many or all microorganisms, with the exception of bacteria spores, from inanimate objects Ishihara Book ✔✔used to test color vision. If the patient misses four or more, there might be a color deficiency tympanometry ✔✔the use of air pressure in the ear canal to test for infections or presence of fluid in the middle ear Yellow Stopper color ✔✔Sodium Polyanethol sulfonate (SPS) Yellow Lab Use ✔✔for blood culture specimen collection in microbiology Light Blue Stopper Color ✔✔Sodium citrate (anticoagulant) Light Blue Lab Use ✔✔Coagulation studies Red Stopper Color ✔✔Plastic: clot activator Glass: no additive (plain) Red Lab Use ✔✔for serum determinations and may be used for routine blood donor screening and diagnostic testing of serum for infectious diseases Gold or tiger top (red-grey) Stopper Color ✔✔- Serum separator tube (SST) - Clot activator - Thixotropic gel (creates barrier) Gold or tiger top (red-grey) Lab Use ✔✔for serum determinations and may be used for routine blood donor screening and diagnostic testing of serum for infectious diseases Green Stopper Color ✔✔Sodium Heparin and Lithium Heparin Green Lab Use ✔✔for plasma determinations in chemistry Lavender Stopper Color ✔✔EDTA (anticoagulant) Lavender Lab Use ✔✔WHOLE BLOOD hematology determinations, routine immunohematology testing and blood donor screening Gray Stopper Color ✔✔Potassium oxalate and sodium fluoride Gray Lab Use ✔✔Glucose testing (GTT) Medial Cubital Vein ✔✔On the anterior surface of the vein. Vein of choice in intravenous injections. Cephalic Vein ✔✔Large vein on the *outermost* side of the upper arm Basilic Vein ✔✔large vein on the *inner* side of the upper arm Bipolar Leads ✔✔Leads I, II, III - record impulses that travel from a negative to positive pole Unipolar Leads ✔✔aVR, aVL, aVF (augmented) Augmented ✔✔having been made greater in size or value White electrode ✔✔right arm Black electrode ✔✔left arm Red electrode ✔✔left leg Green Electrode ✔✔right leg Chest Lead placement ✔✔ Filing systems and processes ✔✔- Conditioning - Releasing - Indexing and coding - Sorting - Storing and filing Conditioning ✔✔involves grouping related papers together, removing all paper clips and staples, attaching smaller papers to regular sheets, and fixing damaged records Releasing ✔✔marking the form to be filed with a mark of designated preference - ready to be filed - provider's initials - using a stamp Accounts receivable ✔✔amount owed to the provider for the services rendered Accounts payable ✔✔debt incurred but not yet paid Assets ✔✔property of an individual or organization LIABILITIES + CAPITAL = ASSETS Liabilities ✔✔items that are outstanding (debts) Capital ✔✔what has been paid Malfeasance ✔✔performance of an unlawful, wrongful act (EX: performing a procedure on the wrong patient) Misfeasance ✔✔performance of a lawful action in an illegal or improper manner (EX: performing on the correct pt but doing it incorrectly) Nonfeasance ✔✔failure to perform a task, duty, or undertaking that one has agreed to perform or has a legal duty to perform Living will ✔✔A document that indicates what medical intervention an individual wants if he or she becomes incapable of expressing those wishes and under what conditions Durable power of attorney for health care ✔✔A type of advance directive executed by a competent adult that appoints another individual to make medical treatment decisions on his or her behalf in the event that the person making the appointment loses decision-making capacity. MOLST ✔✔Medical document that specifies which treatments will be allowed during end of life care. these orders move with the patient if they move facilities, and is bright pink Bundled Coding ✔✔combining two or more codes into one. Doing so allows them to replace two codes with one overarching code and pay the provider only for the amount allowed under the more dominant code Electronic Health Record (EHR) ✔✔An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across MORE THAN ONE healthcare organization Electronic Medical Record (EMR) ✔✔An electronic record of health-related information about an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within a SINGLE healthcare organization. Order of Cleaning Instruments ✔✔- Sanitization - Disinfection - Sterilization (chemical or autoclave) Isopropyl Alcohol ✔✔used for phlebotomy procedures other than blood cultures Chlorhexidine ✔✔used to clean skin before a blood culture draw Benzoin Tincture ✔✔used to clean skin before applying an adhesive dressing Manifestation of Congestive Heart Failure ✔✔shortness of breath, fatigue, and edema AC interference ✔✔uniform spikes on an EKG caused by electrical interference Somatic Tremor ✔✔artifact caused by voluntary or involuntary muscle movement Subcutaneous Injection ✔✔- pinch the skin at the injection site to make sure the medication goes into the subcutaneous tissue - inject at a 45-90 degree ankle, bevel up - slowly inject the medication Weber ear test ✔✔- used to determine if one ear is better than the other -ask the pateient if they hear the vibration louder in one ear than the other. Rinne test ✔✔hearing acuity test performed with a vibrating tuning fork that is first placed on the mastoid process and then in front of the external auditory canal to test bone and air conduction CPT Code ✔✔Procedural description with a five-digit identifying code number (can add 2 more digits that adds more information about it) Chain of Custody Guidelines ✔✔- Drug screens - Forensic studies - blood alcohol levels - Parentage testing (paternity test) RACE (fire safety) ✔✔rescue, alarm, confine, extinguish Cardiac event monitor ✔✔A RECORDING DEVICE THAT CAN RECORD CARDIAC ACTIVITY FOR AT LEAST 30 DAYS - change the electrodes daily - continue with normal daily exercise Papule ✔✔small, solid, raised lesion on surface of the skin Macule ✔✔flat, colored spot on the skin (freckle) vesicle skin lesion ✔✔blister Pustules ✔✔Variously sized circumscribed elevations containing pus OSHA form 301 ✔✔*Injury and illness incident report *Use this to report what happened when an employee experiences a work related injury or illness *Must complete form or an acceptable substitute such as state workers compensation form within 7 calendar days after notification of injury or illness Encounter Form ✔✔A document used to collect data about elements of a patient visit that can become part of a patient record or be used for management purposes. Cryoprobe ✔✔an instrument for applying extreme cold to tissue Senn Retractor ✔✔used to hold back tissue from the surgical wound Cytobrush ✔✔use this to collect endocervical cell samples Adson forceps ✔✔stainless steel tweezers used to move and hold tissue in place during delicate surgical procedures Stream scheduling ✔✔An appointment scheduling method in which each patient is given a different, specific appointment time. Also called fixed appointment scheduling, time-specified scheduling, or single booking. Modified wave scheduling ✔✔system where multiple patients are scheduled at the beginning of each hour, followed by single appointments every 10 to 20 minutes the rest of the hour POMR problem list ✔✔Lists all of the patient's problems. The title may be a diagnosis, a finding, a symptom, or an abnormal lab result. New problems are added as they arise. Resolved problems are marked and dated as such. POMR progress notes ✔✔chief complaint and doctors notes POMR diagnostic and treatment plan ✔✔doctor's referrals, treatment plan POMR database ✔✔patient's health history and lab results Strabismus ✔✔crossed eyes nystagmus ✔✔Involuntary rapid eye movements Conjunctivitis ✔✔pink eye, bacterial infection Hordeolum ✔✔sty; an acute infection of a sebaceous gland of the eyelid Hemoptysis ✔✔coughing up blood Melena ✔✔coffee ground appearance stool (from blood) hemotemesis ✔✔vomiting blood Otalgia ✔✔pain in the ear Tinnitus ✔✔ringing in the ears Presbycusis ✔✔age related hearing loss How far away does the patient stand for a Snellen chart vision test? ✔✔20 feet Curette ✔✔spoon-shaped instrument used to scrape tissue from body cavities CHF manifestations ✔✔shortness of breath, fatigue, and edema Abandonment ✔✔provider lets a patient go without notice, short staffed Slander ✔✔the action or crime of making a false spoken statement damaging to a person's reputation Assault ✔✔threat or attempt to injure Battery ✔✔unlawful touching of another person without consent defamation ✔✔either slander or libel and damaged a person's reputation - slander: false spoken claim - libel: published false statement diaphoretic ✔✔profuse sweating eupnea ✔✔normal breathing dyspnea ✔✔difficulty breathing fecal occult test ✔✔test of stool specimen for the presence of minute amounts of blood - smear small layer onto stool test card