Ma Notes

Contacts Phone/E-Mail
Name
Ph: e-mail:
Name
Ph: e-mail:
Name
Ph: e-mail:
Name
Ph: e-mail:
Name
Ph: e-mail:
Name
Ph: e-mail:
Name
Ph: e-mail:
Name
Ph: e-mail:
Name
Ph: e-mail:
Name
Ph: e-mail:
Name
Ph: e-mail:
Name
Ph: e-mail:
4561_FM_0002-0002.indd 24561_FM_0002-0002.indd 2 10/20/2015 11:32:34 AM10/20/2015 11:32:34 AM

MA
Notes
MA
Notes
Medical Assistant’s Pocket Guide
Cindi Brassington, MS, CMA (AAMA)
Cheri Goretti, MA, MT (ASCP),
CMA (AAMA)
Purchase additional copies of this book at
your health science bookstore or directly
from F.A. Davis by shopping online at www.
fadavis.com or by calling 800-323-3555 (US)
or 800-665-1148 (CAN)
FA Davis’s Notes Book
3rd Edition
4561_FM_0002-0002.indd i4561_FM_0002-0002.indd i 10/20/2015 11:32:34 AM10/20/2015 11:32:34 AM

F.A. Davis Company
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4561_FM_0002-0002.indd ii4561_FM_0002-0002.indd ii 10/20/2015 11:32:35 AM10/20/2015 11:32:35 AM

4561_FM_0002-0002.indd iii 4561_FM_0002-0002.indd iii 10/20/2015 11:32:35 AM 10/20/2015 11:32:35 AM

   Look for our other Davis’s Notes titles
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4561_FM_0002-0002.indd iv4561_FM_0002-0002.indd iv 10/20/2015 11:32:35 AM10/20/2015 11:32:35 AM

1
ADMIN
HIPAA
The Health Insurance Portability and Accountability Act (HIPAA)
of 1996 mandates privacy for health information, standards for
electronic transactions of health information and claims, security
of electronic health information, and national identiﬁ ers for the
parties in health care transactions.
Glossary of HIPAA Terms
The following terms appear in HIPAA guidelines and are used in
determining when and how to store and release health
information.
Business Associate
A person who, on behalf of the covered entity, performs or
assists in the performance of a function or activity involving
the use of individually identiﬁ able health information (IIHI). (Does
not include members of the covered entity’s workforce.) Exam-
ples include legal, actuarial, accounting, consulting, and auditing
ﬁ rms.
De-Identiﬁ ed Information (DII)
Health information that has had all personal identiﬁ ers removed
from the data set. May be disclosed without consent of the
individual.
Disclosure
Releasing, transferring, providing access to, or divulging in any
manner information outside the entity holding the information.
Health Care Operations
Refers to using protected health information (PHI) to support
business activities of a practice. This may include employee
training, marketing, fund-raising, licensing, and quality
assessments.
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2
ADMIN
Individually Identiﬁ able Health
Information (IIHI)
Created by a health care organization, relates to past, present, or
future condition of an individual, and could be used to identify
that individual.
Patient Identiﬁ able Information (PII)
Identiﬁ ers within health information that could be used to iden-
tify an individual.
Payment
Refers to using PHI to obtain payment of health care services.
This may include the operations a health insurance plan under-
takes before paying for services.
Privacy Standard
Having policies and procedures in place to control who has
access to protected health information (PHI).
Protected Health Information (PHI)
Any patient identiﬁ able information regardless of the media form
it is in, whether at rest or in transit.
Security Standard
Protect the Conﬁ dentiality, Integrity, and Availability
of PHI

■ Conﬁ dentiality is the prevention of unauthorized disclosure
of data.
■ Integrity is the prevention of unauthorized modiﬁ cation of
data.
■ Availability is the prevention of loss of access to resources
and data.
Treatment
Refers to using PHI to provide, coordinate, or manage health care
and related services.
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3
ADMIN
Use
Refers to sharing, employing, applying, utilizing, examining, or
analyzing individually identiﬁ able health information by employ-
ees or other members of an organization’s workforce.
Workforce
Employees, volunteers, trainees, and other people under the
direct control of a covered entity.
Individual Patient Rights
Patients Always Have the Right to Request
■ Access to information.
■ Amendment of PHI.
■ Additional restriction of information.
■ Alternative communications.
■ Accounting of disclosures.
Components of the Medical Record
Protected Information in the Medical Record
■ Patient registration form
■ Insurance information
■ Consent forms
■ HIPAA forms
■ Health history form
■ Physical examination
■ Progress notes
■ Laboratory reports
■ Diagnostic reports (x-ray, MRI, ECG, etc.)
■ Medication record
■ PT, OT reports
■ Homecare reports
■ Hospital documents (OP, D/C, pathology reports)
■ Correspondence
■ Consultation reports
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4
ADMIN
Safeguards for PHI
Administrative
■ Verify identity of person picking up health records.
■ Verify identity of person on telephone.
■ Report suspected breach in conﬁ dentiality.
■ Ask all patients to read and sign notice of privacy practices (NPP).
Technical
■ Require a unique password and user name for each staff
member accessing medical records.
■ Use and regularly update ﬁ rewall protection to prevent
“hacking.”
■ Delete user names and passwords of employees who leave
the practice.
■ Utilize tracking software to monitor employees’ activities in
the system.
■ Require that staff members log off when away from
computer.
Physical
■ Store patient ﬁ les away from patient-accessible areas.
■ Lock ﬁ le cabinets.
■ File medical records before cleaning staff come in at the end
of each day.
■ Do not post provider schedules with patients’ names in
areas where other patients can see.
■ Sign-in sheets in the waiting room are okay; instruct patients
to use ﬁ rst name and last initial only.
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5
ADMIN
Disclosure of Protected Health Information
What Can I Say, What Can’t I Say?
If a friend or family member asks for information regarding a
speciﬁ c patient—BY NAME, you may:
Disclose Don’t Disclose
Location of the patient and
general condition:
Speciﬁ c conditions:
• “She is in room 1133, in
stable condition.”
• “He is in ICU, in critical
condition.”
• “Her fractured leg has been
casted and she has been
sedated.”

• “Inoperable tumors were found
during his surgery.”
PHI for treatment, payment,
and operations (TPO)
PHI for other than TPO
Treatment, payment, and
health care operations
“PHI is never given out without
authorization; if you obtain signed
authorization from the patient, I
can release the requested
information.”
Any DII DII can be disclosed without
consent because personal
identiﬁ ers are omitted in the data
(used for research, public health,
etc.).
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6
ADMIN
Authorization to Release Health
Care Information
Patient______________________________________________________
Date__________________________________________________________
Patient ID# ___________________________________________________
I request and authorize ______________________________ ofﬁ ce to
release the health care information of ______________________
(patient name) to (name and address of destination of the
medical information):
_______________________________________________________________
_______________________________________________________________
This request and authorization applies to (sign appropriate lines):
1. All health care information EXCLUDING speciﬁ c information
relating to sexually transmitted diseases, HIV/AIDS diagnosis
and treatment, alcohol and/or drug history, and any care
related to psychiatric disorders and mental health.
___________________________________________________________
2. All health care information INCLUDING speciﬁ c information
relating to sexually transmitted diseases, HIV/AIDS diagnosis
and treatment, alcohol and/or drug history, and any care
related to psychiatric disorders and mental health.
___________________________________________________________
I understand that my expressed consent is required for release
of information relating to diagnosis and treatment of sexually
transmitted diseases, HIV/AIDS, drug and alcohol abuse, and
psychiatric disorders and mental health care. If I have been
tested, diagnosed, or treated for the aforementioned, permission
by my signature at the item authorizes you to release information
regarding that testing, diagnosis, and/or treatment.
_______________________________________________________________
Signature of patient or authorized representative
________________________ ____ _______________________
Relationship to patient Date
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7
ADMIN
Disclosures for Public Interest
The following disclosures are permitted without the individual’s
authorization because these items have an impact on public
health and/or safety.
Court Orders
Can be obtained without patient’s consent if ordered by a judge.
Communicable Diseases and Work-Related
Illnesses and Accidents
Disclosure to public health authorities is used to prevent acci-
dents and illness and monitor trends.
Reporting Victims of Abuse, Neglect, or
Domestic Violence
Health care providers are legally responsible for reporting cases
to social services and law enforcement.
Law Enforcement Purposes
■ To identify missing persons or a suspect
■ To alert police of death of a suspect
■ When PHI is evidence of crime or can be used as such
■ When there is perceived serious threat to patient
Deceased Persons
PHI may be disclosed for the purpose of organ and tissue trans-
plant/donation.
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8
ADMIN
Privacy Policy Documents
Notice of Privacy Practices
Describes the use of PHI for carrying out treatment, payment, or
health care operations. A written acknowledgement is recom-
mended rather than verbal.
Consent for Use or Disclosure for TPO
Patient consent to the use of and disclosure of health information
for treatment, payment, or health care operations (TPO)
(optional).
Authorization
Authorization to use or disclose PHI must be obtained when a
consent form does not apply or another exception otherwise
permitting use or disclosure of PHI does not apply. See page 6.
Business Associate Contract (BAC)
Describes protection of privacy of a patient’s PHI when using
outside entities that provide services for your organization where
access to PHI is necessary.
Data Use Agreement
An agreement with a recipient of the PHI data that limits his or
her use of PHI.
Privacy Ofﬁ cer Job Description
A written description of the Privacy Ofﬁ cer’s roles and
responsibilities.
Termination Procedure
A written policy of termination of employees who fail to comply
with internal privacy policies and procedures.
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9
ADMIN
What to Include
A complete
Notice of Privacy
form will include: Notice of Privacy Practices
What will
information be
used for?
We use health information about you for treatment, to obtain payment, for
administrative purposes, and to evaluate the quality of care that you
receive.
Can information
be used for
anything else?
We may use or disclose identiﬁ able health information about you without
your authorization for public health purposes, for auditing, and for
research studies (subject to certain requirements).
Limitations of
disclosure?
In any other situation, we will ask for your written authorization before
using or disclosing any identiﬁ able health information about you.
Patient’s rights In most cases, you have the right to look at or get a copy of health
information about you that we use to make decisions about you. Copies
can be provided for $0.05 per page. You also have a right to receive a list
of instances in which we have disclosed health information about you for
reasons other than treatment, payment, or related administrative
purposes. If you believe that the information in your record is incorrect or
if important information is missing, you have the right to request that we
correct the existing information or add missing information.
Continued
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10
ADMIN
What to Include
A complete
Notice of Privacy
form will include: Notice of Privacy Practices
Complaints If you are concerned that we have violated your privacy rights, you may
contact the person below. (HIPAA compliance ofﬁ cer or ofﬁ ce manager
should be referenced.)
Legal duty of
ofﬁ ce
We are required by law to protect the privacy of your information, provide
this notice about our information practices, and follow the information
practices that are described in this notice.
For questions or complaints, please contact:
Name, address, phone
Adapted from http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.htmlNPP information:
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11
ADMIN
Seven Components of a Compliance Plan per
Recommendations of the Ofﬁ ce of Inspector
General (OIG)

■ Conduct periodic internal monitoring and audits.
■ Implement compliance and practice standards.
■ Designate a HIPAA compliance ofﬁ cer.
■ Conduct training and education.
■ Respond appropriately to detected offenses and develop a
corrective action plan.
■ Develop open lines of communication to staff for asking
questions and refer to the policies and procedures manual.
■ Enforce disciplinary standards through well-publicized
guidelines that are explained in detail in the policies and
procedures manual.
Web Resources for HIPAA
Health Insurance Portability and Accountability Act of 1996: Title
1 Statutory Text

http://www.cms.gov/Regulations-and-Guidance/HIPAA-
Administrative-Simpliﬁ cation/HIPAAGenInfo/index.html
HIPAA Academy
http://www.HIPAAacademy.net
American Medical Association—HIPAA: Health Insurance Porta-
bility and Accountability Act

http:// www.ama-assn.org/go/hipaa
U.S. Department of Health & Human Services–Health Informa-
tion Privacy

http: //www.hhs.gov/ocr/privacy/
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12
ADMIN
Notes

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13
ADMIN
Electronic Health Records
Electronic health records (EHR) features:
1. Patients’ personal and medical data (input by MA or
physician).
2. Insurance billing through paperless Internet-encrypted
connections to third-party payors.
3. Prescription information periodically updated to ensure that
physicians prescribe correct dosages and do not prescribe in
conjunction with contraindicated medications.
4. Diagnosis and procedure codes periodically updated to
currently accepted codes.
5. Physician chart notes easily accessible when needed as
supporting documentation.
6. X-rays, CT scans, and MRIs digitally stored and retrieved at
multiple locations.
What Do I Need to Remember When Using
Electronic Health Records?
1. Be careful when inputting patient data. Errors in spelling or
errors in insurance ID#s will cause denial of payment.
2. Use encrypted connection when sending claims for
payment.
3. Send supporting documentation for payment as requested
in format requested by the insurer (PDF ﬁ les, JPEG scans,
etc.).
4. All HIPAA guidelines for security and privacy apply to EHR
and paper documentation.
5. Notice of privacy practices (NPP) should be obtained from
patients with their signature and scanned into the EHR.
6. Back up EHR to encrypted Web storage or off-site storage as
directed by practice policy.
7. Never use ofﬁ ce computers for unauthorized purposes since
viruses could corrupt the integrity and/or privacy.
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14
ADMIN
Filing Systems
Medical records must be accessible for use. A consistent ﬁ ling
system ensures proper access. Remember to keep medical
records conﬁ dential.
Alphabetical
Alphabetical ﬁ ling systems order patient records by name.
UNIT 1 UNIT 2 UNIT 3 UNIT 4
LAST NAME FIRST NAME MIDDLE
NAME/INITIAL
TITLE(if
applicable)
Put Nothing Before Something
For example, Ann before Anne:
■ Jones, Ann
■ Jones, Anne
■ Jones, Anne M
■ Jones, Anne Marie (Anne before Anne M, before Anne
Marie)
■ Jones, Anne Marie II
Treat Hyphenated Names as One Name
For example:
■ JonesRodrigues, Ann
Alphabetize Titles
For example, Jr. before Sr.:
■ Kalinsky, Jerry Jr.
■ Kalinsky, Jerry Sr.
Blank before I (nothing before something), I before II:
■ Robert Muszinsky
■ Robert Muszinsky I
■ Robert Muszinsky II
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15
ADMIN
Ignore Capitalization Within a Surname
File in ABC order:
■ MacDonald, Joe
■ McDonald, Joe
Married Versus Maiden Names
If M s. Jones uses only the married name Rodrigues:
■ Rodrigues, Ann Jones
If Ms. Jones marries Mr. Rodrigues and hyphenates her name:
■ JonesRodrigues, Ann
Hyphenated Names
Use a cross-reference guide:
■ Jones, Ann see: JonesRodrigues, Ann
Two Patients With Same Name
Use address to ﬁ le in order according to this chart:
UNIT 1 UNIT 2 UNIT 3 UNIT 4
CITY STATE STREET NAME STREET NUMBER
So, Mason before Washington:

Gary E. Burns
15 Mason Road
Willington, CT

Gary E. Burns
7 Washington Blvd
Willington, CT

And Willington before Windham:

Gary E. Burns
7 Washington Blvd
Willington, CT

Gary E. Burns
1 Adams Street
Windham, CT
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16
ADMIN
Numeric
Consecutive Filing
File by increasing number. Think of counting in sequence:
573902 (or 57-39-02)
573903
573904
573905
Nonconsecutive Filing Systems
File by a primary unit other than the ﬁ rst digits in sequence.
Terminal Digit Filing
3 2 1
File the last two digits ﬁ rst 43 22 15
The second set is then used 43 23 15
Then the ﬁ rst units 44 23 15
43 22 16
42 21 17

NOTE: Terminal digit ﬁ ling can be used to ﬁ le patients by age.
The last two digits could correspond to the year of birth. Any one
of the sets of numbers could correspond to other variables, such
as the treating physician, the ofﬁ ce site, month codes for appoint-
ment reminders, and so on.
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17
ADMIN
Middle Digit Filing
2 1 3
File the middle two digits ﬁ rst 42 21 17
The ﬁ rst set is ﬁ led second 43 22 15
The last set is ﬁ led third 43 22 16
FILE NUMBER SIGNIFICANCE IN MY OFFICE :

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18
ADMIN
Communication Skills
The Five Cs of Communication
Complete, Clear, Concise, Courteous,
and Cohesive

Sender
Encodes
message
Feedback
Receiver
Decodes message
Message
Speaking
Listening
Gesturing
Writing

Sender, Message, Receiver, and Feedback
Forms of Communication
Written Communications
Written communications sent via U.S. mail have an expectation
of privacy and can contain PHI for appropriate use. Written com-
munications can be used to relate information to:
■ Patients
■ Insurance providers
■ Attorneys
■ Law enforcement agencies
■ Social services
■ Other physicians or providers
■ Hospitals
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19
ADMIN

August 13, 2015
ABC Medical Office
123 Main Street
Willington, CT 06274
Mrs. Hannah Collins
45 Myrtle Way
Willington, CT 06279
Dear Mrs. Collins:
RE: Yearly physical
Our records indicate that it has been one year since your last
physical examination. Please call the office to schedule an appointment.
Thank you,
Amy Chen, CMA
1. DATE LINE
Parts of a LetterLeft margin, 2 to 3 lines below
letterhead
2. RETURN ADDRESS
Left margin, 2 lines below date
4. SALUTATION
Left margin, 2 lines below inside address
Other examples:
Dear Mr./Ms.:
To Whom It May Concern:
6. INTRODUCTORY STATEMENT
Left margin, 2 lines below salutation
(or subject line, if applicable)
Other examples:
As per our recent conversation,
In answer to your inquiry,
Please be advised
8. COMPLIMENTARY CLOSING
Left margin, 2 lines below body of letter
Other examples:
Best of health (used in medicine),
Respectfully yours,
Respectfully,
Very truly yours,
Sincerely,
Regards,
Best wishes,
3. INSIDE ADDRESS
Left margin, 2 lines below date
7. BODY OF LETTER
Left margin, 2 lines below
salutation (or subject line,
if applicable)
5. SUBJECT LINE
Left margin, 2 lines below salutation
Other examples:
RE: Welcoming Our New Physician
RE: Patient name, topic, etc.

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20
ADMIN
Commonly Misspelled Words
Abscess Chancre Hemorrhoid Parietal
Aerobic Deﬁ brillator Homeostasis Perineum
Aneurysm Desiccation Humerus Peritoneum
Asepsis Dissect Ischium Specimen
Asthma Epididymis Occlusion Surgeon
Benign Fissure Osseous Vaccine
Capillary Glaucoma Parenteral
Telephone Communications
Telephone privacy can be maintained in the ofﬁ ce by closing a
door or reception screen. Always ask the identity of the caller
and give out information regarding a speciﬁ c patient according
to HIPAA guidelines (see page 5). Also:

■ Greet the caller and identify yourself.
■ If you need to place the caller on hold, ask if you can do so:
“Can you hold please?”
■ When returning to the call, conﬁ rm the identity of the caller,
“Ms. Collins?”
■ When offering an appointment, offer speciﬁ c times. For
example, “We can see you at 3 or 4:30 today.”
Scheduling New Patients

■ Be sure to get:
■ Patient’s telephone number
■ Patient’s date of birth
■ Type of insurance and insurance ID#
■ Reason for appointment
■ Name of referring physician (if applicable).
■ Offer directions to the ofﬁ ce.
■ Ask the patient to bring photo ID for ﬁ rst visit.
■ Explain copayment policy. For example, “Copayment is due
at time of visit.”
■ Repeat the day and time of the appointment at the end of
the phone call.
■ Other items ________________________________________.
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21
ADMIN
Scheduling Established Patients
■ Patient’s name
■ Reason for visit
■ Has insurance information changed since last visit?
■ Referral, if applicable
■ Other items ________________________________________
Time Required for Treatment
Write in the amount of time and room requirements for appoint-
ments as indicated below.
New Patient Examination _________minutes Room_________
Established Patient
Examination
_________minutes Room_________
Follow-up Visit _________minutes Room_________
Consultation _________minutes Room_________
Blood Testing _________minutes Room_________
X-rays _________minutes Room_________
ECG _________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
Continued
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22
ADMIN
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
_________minutes Room_________
E-mail Communications
Do not expect privacy when using e-mail as a method of com-
munication. Not all e-mail recipients have exclusive access to
their e-mail account. Thus, you should never refer to PHI in an
e-mail.
Fax Communications
Faxing documents that contain PHI poses risks. If you must fax,
be sure to:
■ Recheck the fax number before hitting send.
■ Recheck authorization to release PHI.
■ Always use a cover sheet (see below).
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23
ADMIN
Sample Fax Cover Sheet
ABC Medical Ofﬁ ce
123 Main Street
Willington, CT 06279
TO: _____________
FAX #:
Page 1 of ___

Privacy Notice:
This fax transmission contains conﬁ dential information. This
information is solely for the intended recipient. Be aware that
disclosure, copying, distribution, or use of the contents of this
information is prohibited. If you have received this fax in error,
please notify us at ABC Medical Ofﬁ ce at 860-555-9868 or by
e-mail at [email protected]
What Form of Communication Should I Use?
Written Telephone E-mail
Appointment
reminders,
scheduling
Yes Yes* Yes
PHI Yes With the patient, not left
on answering machine
No
Schedule
changes
Yes, but may
not be practical
Yes* Yes
Requests for
payment
Yes Yes, at patient’s home,
not workplace
Yes
Insurance
questions
Yes Yes Yes
*Be careful when communicating about mental health, substance abuse, and
reproductive health appointments via telephone. It is recommended that
information regarding these appointments not be left on an answering machine
for people who do not live alone.
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24
ADMIN
Banking
BEFORE YOU MAKE A BANK DEPOSIT
■ Does the number of checks in the deposit equal the number
of checks recorded?
■ Are all checks stamp-endorsed for deposit?
■ Check petty cash/change drawer and replenish change for
next day’s transactions.
■ Add checks and cash for total deposit.
■ Recheck math for accuracy.
■ Record amount of deposit.
■ Check the bank’s deposit amount to match recorded amount.

LIST CHECKS SINGLY OR ATTACH LIST
DOLLARS CENTS
CURRENCY
COINS
LIST EACH CHECK CHECKS AND OTHER ITEMS ARE RECEIVED FOR DEPOSIT SUBJECT TO THE PROVISIONS OF THE UNIFORM COMMERCIAL CODE OR ANY APPLICABLE COLL ECTION AGREEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Total from
reverse side
TOTAL$
RE-ENTER
TOTAL HERE
PLEASE BE SURE ALL ITEMS ARE PROPERLY ENDORSED.
FIRST BANK
$

Bank Deposit Slip
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25
ADMIN
General Administrative Ofﬁ ce Tips
Opening the ofﬁ ce each morning:
____1. Check answering machine or service for messages.
____2. Prioritize return phone calls.
____3. Log on to computer network.
____4. Print and post schedule.
____5. Check petty cash fund to ensure daily change, as needed.
____6. Check all rooms for cleanliness; prepare rooms if indicated.
____7. Inspect waiting room for cleanliness, hazards, and so on.
My password hint: __________________________________________
(NOTE: Write a hint that is not easily guessed by anyone else.
Do not write the password itself.)
Password expiration date: ___________________________________
During the day:
____1. File paper charts when able.
____2. Recheck authorization when disclosing PHI.
____3. Pick up waiting room and ofﬁ ce space as needed.
____4. Stagger lunch and coffee breaks to ensure continuous
coverage of phones.
____5. Log off of the computer system when you go to lunch
or break.
____6. Write messages immediately to avoid forgetting
information.
____7. Have parcel packages and laboratory specimens ready
for pickup at courier-designated times.
Closing the ofﬁ ce each day: _________________________________
____1. File patient medical records prior to arrival of cleaning staff.
____2. Prepare bank deposit and designate employee to go to
the bank.
____3. Balance the day sheet or computerized system for the day.
____4. Log off of all computers and turn off the printer.
____5. Check the fax machine for paper in case of transmission
after hours.
____6. Turn off lights in treatment rooms, administrative area,
and reception area.
____7. Lock doors and set the alarm, per ofﬁ ce policy.
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26
ADMIN
Notes

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27
MED INS
Billing
Billing for patient visits in a physician’s ofﬁ ce or hospital setting
must be done without error to guarantee timely payment.
Proper coding of diagnoses to support treatment codes is also
vital to the ﬁ nancial health of a medical ofﬁ ce.
What Do I Need to Process a Request
for Payment?
   ■ Patient’s legal name
   ■ Relationship to insured (self, spouse, child, other)
   ■ Address and telephone number
   ■ Individual identiﬁ cation number and Social Security number
   ■ Group identiﬁ cation number
   ■ Employer of insured party
   ■ Claims address, department, proper P.O. Box
   ■ Date of service
   ■ Diagnostic codes (that support treatment)
   ■ Treatment codes
New Patients
■ Photocopy of insurance card (placed in patient’s ﬁ le or
added to electronic health record)
   ■ Veriﬁ cation of eligibility (call, fax, or Internet veriﬁ cation)
   ■ Photocopy of driver’s license or other photo identiﬁ cation
(placed in patient’s ﬁ le)
Existing Patients
■ Has your insurance changed?
   ■ Has your name, address, phone number, or e-mail address
changed?
   ■ Has your employment changed?
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28
MED INS
CMS-1500 (02–12) Form
Source: Centers for Medicare & Medicaid Services . For complete instructions for CMS forms, go to: http://www.nucc.org/images/stories/
PDF/1500_claim_form_instruction_manual_2012_02.pdf
1.
2. PATIENT’S NAME (Last Name, First Name, Middle Initial)
5. PATIENT’S ADDRESS (No., Street)
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)
a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous)
b. AUTO ACCIDENT? PLACE (State)
c. OTHER ACCIDENT?
10d. CLAIM CODES (Designated by NUCC)
b. RESERVED FOR NUCC USE
c. RESERVED FOR NUCC USE
d. RESERVED FOR NUCC USE
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information
necessary to process this claim. I also request payment of government benefits either to myself or to the party who
accepts assignment below.
SIGNED DATE
CITY STATE
ZIP CODE TELEPHONE (Include Area Code)
( )
3. PATIENT’S BIRTH DATE
6. PATIENT RELATIONSHIP TO INSURED
8. RESERVED FOR NUCC USE
10. IS PATIENT’S CONDITION RELATED TO:
Self
MM DD YY
MEDICARE
(Medicare#)
MEDICAID
(Medicaid#)
TRICARE
(ID#/DoD#)
CHAMPVA
(Member ID#)
GROUP
HEALTH PLAN
(ID#)
MF
FECA
BLK LUNG
(ID#)
OTHER
(ID#)
1a. INSURED’S I.D. NUMBER
4. INSURED’S NAME (Last Name, First Name, Middle Initial)
7. INSURED’S ADDRESS (No., Street)
11. INSURED’S POLICY GROUP OR FECA NUMBER
(For Program in Item 1)
Spouse
Child
Other
SEX
a. INSURED’S BIRTH DATE
b. OTHER CLAIM ID (Designated by NUCC)
c. INSURANCE PLAN NAME OR PROGRAM NAME
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE
I authorize payment of medical benefits to the undersigned
physician or supplier for services described below.MM DD YY
MF
YES NO If yes, complete items 9, 9a, and 9d.
YES NOYES NOYES NO
SEX
CITY STATE
ZIP CODE TELEPHONE (Include Area Code)
( )
SIGNED
PATIENT AND INSURED INFORMATION
x
x
x
x
sof sof
XYZ123000
Doe, Jane A
10 Elm Street
Blueville
06000
98700
CT
03 08 1979
x
x
x
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29
MED INS
           Source: Centers for Medicare
&
Medicaid Services
.
     For complete instructions for CMS forms, go to:

  http://www.nucc.org/images/stories/PDF/1500_claim
_form_instruction_manual_2012_02.pdf

14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP)17. NAME OF REFERRING PROVIDER OR OTHER SOURCE19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC)21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E)25. FEDERAL TAX I.D. NUMBER SSN EIN
SIGNED
NUCC instruction Manual available at: www.nucc.org
PLEASE PRINT OR TYPE
APPROVED OMB-0938-1197 FORM 1500 (02-12)
DATE
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
INCLUDING DEGREES OR CREDENTIALS(I certify that the statements on the reverse apply to this bill and are made a part thereof.)
32. SERVICE FACILITY LOCATION INFORMATION
26. PATIENT’S ACCOUNT NO.
a. b.
27. ACCEPT ASSIGNMENT? (For govt. claims, see back)
28. TOTAL CHARGE $33. BILLING PROVIDER INFO & PH #
( )
29. AMOUNT PAID $
30. Rsvd for NUCC Use
24. A. DATES OF SERVICE
123456
PHYSICIAN OR SUPPLIER INFORMATION
B.
PLACE OF
SERVICE
C.
EMG
E.
DIAGNOSIS
POINTER
F.
$ CHARGES
G.
DAYS
OR
UNITS
H.
EPSOTFAMILY
PLAN
I.
ID.
QUAL.
J.
RENDERING
PROVIDER ID. #
D. PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS MODIFIER
From
11 04 2014 11 04 201411 11 2014 11 11 201411 11 2014 11 11 2014
111111
992022905585025
00000000
11 11 2014
DOEJA001
ABAB
111
NPINPINPINPINPINPI
To
MM DD YY
MM DD YY
ICD Ind.
A.E.
I.
15. OTHER DATE17a.17b. NPIQUAL
QUAL
FROM TO
16.
DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
18.
HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
20. OUTSIDE LAB? $ CHARGES22. RESUBMISSION CODE23. PRIOR AUTHORIZATION NUMBER
MM DD YY
MM DD YY
MM DD YY
ORIGINAL REF. NO.
MM DD YY
YES NO
B.F.J.C.G.K.D.H.L.
a. b.
YES NO
x
Anne Wilson MD15 Main StreetBlueville CT 060000123456789
11
M84 421 E11 321
11 2014 431
0
x
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30
MED INS
NUCC Guidelines for CMS-1500 (02–12)
■
Carrier Block: Located in the upper center and right margin of the form

HEALTH INSURANCE CLAIM FORMAPPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12
PICA
UNITED HEALTH SAMPLE INSURANCE
SUITE 1000
10 MAIN STREET
ANYTOWN CT 06000
CARRIER
PICA

Completed Carrier Block
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31
MED INS
   ■   Item 1:   Choose appropriate insurance carrier.
   ■   Item 1a: Insured I.D. number
   ■ Be sure to write number exactly as on patient’s insurance
card.
   ■   Item 2:   Enter patient’s full name as it appears on insurance
card.
   ■ Doe, Jane, A
   ■ Okay to use commas or hyphen but no periods within
names.
   ■ If the patient is the insured, this item can be left blank.
   ■   Item 3:   Patient’s date of birth
   ■ MM DD YYYY
   ■ Enter X to indicate gender.
   ■   Item 4:   Insured’s name
   ■ Same convention as patient name.
   ■   Item 5: Patient address
   ■ Use no punctuation.
   ■ Example: 100 Elm Street apt 7
   ■ NUCC suggests leaving telephone blank.
   ■ If the patient’s address is the same as the insured, leave
blank.
   ■   Item 7:   Insured address
   ■ If Item 4 is completed, this item should be completed.
   ■ Workers’ comp claims: use employer address.
   ■   Item 9:   Enter name of secondary insured only if Item 11d is
marked yes.
   ■ Use conventions as in previous items.
   ■   Item 9d: Enter secondary insurance plan or program.
   ■   Item 10: Indicate if injury is due to employment, auto
accident.
   ■ Include postal code of state where accident occurred.
   ■ “Other accident” would indicate accident but neither WC
or auto.
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32
MED INS
   ■   Item 10d:   For workers’ comp claims: W2 for duplicate
claims, W3 for Level 1 appeal.
   ■ Item 11:   Insurance policy group number for PRIMARY
insurance (right side of form).
   ■   Item 11b:   Use if property and casualty claim # applies.
   ■   Item 12: Signature on ﬁ le (patient’s) to release information
to insurance company for payment.
   ■ Item 13: Signature on ﬁ le (patient’s) to authorize payment to
ofﬁ ce and not patient.
   ■ Item 14:    Date of current illness, injury, or pregnancy (LMP).
   ■ For services related to an  illness , enter date ﬁ rst
symptoms occurred.
   ■ For  injury related services, enter date of accident.
   ■ For  chiropractic   services, enter ﬁ rst date of treatment.
   ■ For  pregnancy related services, add date of LMP.
   ■ Qualiﬁ er codes:
431   onset of current symptom or illness
484   last menstrual period
   ■   Item 17 : Referring provider, use 2 character qualiﬁ ers:
DK   ordering physician (only for DME claims)
DN   referring provider
DQ   supervising provider
   ■ Item 21: Diagnoses codes (use ICD-9-CM or ICD-10)
   ■ Use ICD-9-CM prior to Oct. 2015, ICD-10 after Oct. 2015.
   ■ Enter applicable ICD indicator to identify which version of
ICD codes is being reported.
• 9 ICD-9-CM
• 0 ICD-10-CM
   ■ Enter the indicator between the vertical, dotted lines in the
upper right-hand portion of the ﬁ eld.
   ■   Item 22 :   Resubmission codes
   ■ Use the following 4-digit codes for resubmission of
claims.
   ■ Used for previously paid claims, including zero paid
claims.
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33
MED INS
   ■ Don’t use codes for denied claims.
1021   late charges received by facility business ofﬁ ce
1023   primary carrier has made additional payment
1028   correcting procedure/service code
1029   correcting diagnosis code
1030   correcting charges
1031   correcting units, visits of studies
1034   correcting quantity dispensed
1035   correcting drug code
1037   services not covered by Medicare
1041   incorrect amount paid for original claim
1042   original claim has multiple incorrect items
1053   adjustment—miscellaneous
   ■   Item 24D: CPT/HCPCS codes for procedures (add modiﬁ er
when necessary).
   ■   Item 24E: Reference ICD-9-CM or ICD-10 code that supports
procedure (use ABCDEFGHIJKL).
   ■   Box 25: Federal Tax ID, doctor’s Social Security number, or
Employer ID number (needed to pay claim).
   ■   Box 33a: National Provider Identiﬁ cation (NPI) number
(check that  number is correct ).
CMS-1500 Checklist

■ Name on CMS-1500 appears exactly as name on insurance
card.
   ■ Insured identiﬁ cation number and group number are correct.
   ■ Patient/insured date of birth is rechecked and uses the
format MM DD YYYY.
   ■ Referring physician name and National Provider
Identiﬁ cation (NPI) are rechecked (if applicable).
   ■ Dates of service are correct and use the format MM DD YYYY.
   ■ Diagnostic and procedure codes are correct.
   ■ Check spelling.
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34
MED INS
Local Insurance Plans and Ofﬁ ce Participation
Use this chart to record insurance participation for reference in your ofﬁ ce. An example is
provided in blue.
Name   In/Out of Network Ofﬁ ce Visit Deductible  Referral  Calendar Year Limit

BC/BS POE

In

$10 copay

None

No

None









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35
MED INS
Glossary of Health Insurance Terms
The following terms and their deﬁ nitions relate to health
insurance.
   Birthday Rule :   Rule that designates the parent with the earlier
birthday in the calendar year as the primary insurer for the
dependent children.
   Clean Claim :   Error-free insurance claim.
   Copay, Copayment :   Amount of money patient owes at each visit
(varies with insurers from $5 to $25).
   Deductible :   Amount of money paid out-of-pocket by the patient
at the beginning of each calendar year before health insurance
beneﬁ ts begin to cover claims.
   Explanation of Beneﬁ ts (EOB) :   Document sent from the insur-
ance company to the patient outlining payment made to the
physician, write-offs, and any patient responsibility.
   Health Maintenance Organization (HMO) :   Organization that
reimburses a health care provider for services delivered to a
covered patient in an individual, group, or public health plan,
according to an agreement between the provider and the HMO.
   Preauthorization :   Insurance company review and authorization
of a treatment plan and agreement to pay for such treatment.
   Preferred Provider :   Physician or other health care provider who
signs a contract with an insurance carrier to provide patient care
at a discounted rate.
   Primary Care Provider :    General practitioner designated by the
insurance plan as the ﬁ rst doctor the patient sees for most care.
(Specialist visits require a referral—see  R eferral below.)
   Referral :   Authorization from a primary care provider for a special-
ist to treat a patient for a speciﬁ c injury or illness for a speciﬁ c
number of visits, treatment procedures, and time period.
   Utilization Review :    Process by which a third-party administrator
determines medical necessity of treatment and approves or
denies payment of health care claims.
   Veriﬁ cation :   Process of conﬁ rming insurance beneﬁ ts with the
patient’s insurance carrier.
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36
MED INS
Current Procedural Terminology
Current Procedural Terminology lists recognized codes for pro-
cedures performed in ofﬁ ce and hospital. To order CPT coding
books online, visit  https://commerce.ama-assn.org/store/
CPT Sections

■ Evaluation and Management (E/M) (99201–99600)
   ■ Anesthesia (00100–01999)
   ■ Surgery (10040–69990)
   ■ Radiology (70010–79999)
   ■ Pathology and Laboratory (80048–89399)
   ■ Medicine (90281–99199)
CPT Modiﬁ ers
Modiﬁ er Service
-21   Prolonged E/M services
-22   Unusual procedural services
-23   Unusual anesthesia
-24   Unrelated E/M service by the same physician during a
postop period
-25   Signiﬁ cant, separately identiﬁ able E/M service by the
same physician on the same day of the procedure or
other service
-26   Professional component
-27   Multiple outpatient hospital E/M encounters on the
same date
-32   Mandated services
-47   Anesthesia by surgeon
-50   Bilateral procedure
-51   Multiple procedures
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37
MED INS
CPT Modiﬁ ers —cont’d
Modiﬁ er Service
-52   Reduced services
-53   Discontinued procedure
-54   Surgical care only
-55   Postop management only
-56   Preop management only
-57   Decision for surgery
-58   Staged or related procedure or service by the same
physician during the postop period
-59   Distinct procedural service
-62   Two surgeons
-63   Procedure on infants less than 4 kg
-66   Surgical team
-73   Discontinued outpatient procedure prior to anesthesia
administration
-74   Discontinued outpatient procedure after anesthesia
administration
-76   Repeat procedure by same physician
-77   Repeat procedure by another physician
-78   Return to OR for a related procedure during postop
period
-79   Unrelated procedure or service by the same physician
during the postop period
-80   Assistant surgeon
-81   Minimum assistant surgeon
-82   Assistant surgeon (when qualiﬁ ed resident surgeon
not available)
-90   Reference (outside) laboratory
-91   Repeat clinical diagnostic laboratory test
-99   Multiple modiﬁ ers
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38
MED INS
Common Procedure Codes
Ofﬁ ce or Other Outpatient E/M
Procedure   Code
New patient 99201–99205
Established patient 99211–99215
Common Outpatient Procedures
Procedure   Code
   Amniocentesis   59000
Antepartum care (cesarean section) 59510
Antepartum care (vaginal) 59425–59426
Lipid panel 80061
Renal function panel 80069
Hepatic function panel 88076
TORCH antibody panel 80090
Drug screen 80100
Colonoscopy   45378–45387
Complete blood count 85022–85025
Blood glucose (reagent strip) 82948
Glucose tolerance test (GTT) 82950, 82951
Hemoglobin   85018
Blood testing for lead 83655
Blood testing for prostate speciﬁ c antigen (PSA) 84152
Homocysteine   83090
Injection anesthetic carpal tunnel 20526
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39
MED INS
Common Outpatient Procedures —cont’d
Procedure   Code
Microhematocrit   85013
Occult blood 82270
Pap smear 88141–88145
Photochemotherapy; ultraviolet 96910
Physical therapy evaluation 97001
Proctosigmoidoscopy   45300
Removal foreign body, intranasal; ofﬁ ce 30300
Differential WBC count 85007, 85009
Throat culture 87430
Spirometry   94010
Urinalysis   81000
Urine pregnancy testing 81025
Well child visit V20.2 or
Z00.1 and
E/M code
Routine ECG with at least 12 leads 93000
Tracing only, w/o interpretation or report 93005
Interpretation and report only 93010
Cardiovascular stress test using maximal  or
submaximal treadmill or bicycle
93015
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40
MED INS
Allergy Testing
Procedure Code
Percutaneous tests (scratch, puncture, prick) w/
allergenic extracts, immed type rxn
95004
Percutaneous tests (scratch, puncture, prick) sequential
and incremental, w/drugs, biologicals, or venoms,
immed type rxn
95010
X-Rays
Procedure Code
Chest, single view, frontal 71010
Chest, 2 views, frontal and lateral 71020
X-ray cervical spine, 2 to 3 views 72040
X-ray thoracic spine, 2 to 3 views 72070
X-ray lumbosacral spine, 2 to 3 views 72100
X-ray eye for foreign body 70030
X-ray mandible, less than 4 views 70100
X-ray nasal bones, minimum of 3 views 70140
X-ray sinuses, less than 3 views 70210
X-ray sinuses, paranasal, minimum of 3 views 70220
X-ray skull, less than 4 views 70250
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41
MED INS
Vaccines
Procedure   Code
Adenovirus   90476–90477
Anthrax   90581
Chickenpox   90716
Diphtheria, tetanus, acellular pertussis (DTP) 90696
   Haemophilus inﬂ uenza B (Hib) 90645
Hepatitis B 4156F
Human papillomavirus (HPV)   90649
Measles, mumps, rubella (MMR) 90710
Meningococcal   90734
Pneumococcal   90669
Tuberculosis (BCG) 90585
H1N1 (Swine ﬂ u) 90663
Alternative/Holistic Medicine
Procedure   Code
Acupuncture w/o electrical stimulation 97780
Acupuncture w/electrical stimulation 97781
Chiropractic manipulation 98940, 98941
Osteopathic manipulation 98925
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42
MED INS
Hospital E/M Services
Procedure    Code
Hospital discharge day management 99238
Ofﬁ ce consultations 99241–99245
Initial inpatient consultations 99251–99255
Follow-up inpatient consultations 99261–99263
Conﬁ rmatory consultations 99271–99275
Emergency department visits 99281–99285
Common Procedure Codes









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43
MED INS
International Classiﬁ cation of Diseases
The International Classiﬁ cation of Diseases (ICD) lists recognized
diagnosis codes for diseases, disorders, and syndromes. The ICD
is updated periodically. The 9th edition with clinical modiﬁ ca-
tions (ICD-9-CM) was recently updated to a 10th edition (ICD-10).
T ransition from ICD-9-CM to ICD-10 will be complete by October
1, 2015.
Using the ICD Diseases Index
Here are basic steps for using the diseases index:
1. Locate the main term in the Index to Diseases (Volume 2).
2. If the phrase “see condition” is found after the main term, a
descriptive term (an adjective) or the anatomic site has been
referenced instead of the disorder or the disease (the
condition) documented in the diagnostic statement.
3. When the condition listed is not found, locate main terms
such as syndrome, disease, disorder, derangement of, or
abnormal.
ICD-9-CM Transition to ICD-10
ICD-9-CM codes were accepted through September of 2015. After
October 1, 2015, only ICD-10 codes are accepted.
Basic steps for using the index also apply to ICD-10; however,
note the alphanumeric chapters below.
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MED INS
ICD-10 Chapter List
Chapter     Blocks    Title
I   A00–B99  Certain Infectious and Parasitic Diseases
II   C00–D48  Neoplasms
III   D50–D89  Diseases of the Blood and Blood-Forming
Organs and Certain Disorders Involving
the Immune Mechanism
IV   E00–E90  Endocrine, Nutritional and Metabolic
Diseases
V   F00–F99  Mental and Behavioral Disorders
VI   G00–G99  Diseases of the Nervous System
VII   H00–H59  Diseases of the Eye and Adnexa
VIII  H60–H95  Diseases of the Ear and Mastoid Process
IX   I00–I99  Diseases of the Circulatory System
X   J00–J99  Diseases of the Respiratory System
XI   K00–K93  Diseases of the Digestive System
XII   L00–L99  Diseases of the Skin and Subcutaneous
Tissue
XIII  M00–M99  Diseases of the Musculoskeletal System
and Connective Tissue
XIV   N00–N99  Diseases of the Genitourinary System
XV   O00–O99  Pregnancy, Childbirth and the Puerperium
XVI   P00–P96  Certain Conditions Originating in the
Perinatal Period
XVII  Q00–Q99  Congenital Malformations, Deformations
and Chromosomal Abnormalities
XVIII  R00–R99  Symptoms, Signs and Abnormal Clinical
and Laboratory Findings, Not Elsewhere
Classiﬁ ed
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MED INS
Continued
ICD-10 Chapter List —cont’d
Chapter     Blocks    Title
XIX   S00–T98  Injury, Poisoning and Certain Other
Consequences of External Causes
XX   V01–Y98  External Causes of Morbidity and
Mortality
XXI   Z00–Z99  Factors Inﬂ uencing Health Status and
Contact with Health Services
XXII  U00–U99  Codes for Special Purposes
Comparison of ICD-9-CM to ICD-10
ICD-9-CM   ICD-10
International Classiﬁ cation
of Diseases, 9th edition:
Clinical Modiﬁ cations
International Statistical
Classiﬁ cation of Diseases and
Related Health Problems, 10th
edition
Numeric codes except for
V and E codes
All codes alphanumeric with
leading letter indicating chapter/
body system
Factors inﬂ uencing health
status are V codes
Factors inﬂ uencing health status
are U and Z codes
External causes of
morbidity and mortality
are E codes
External causes of morbidity and
mortality are V, W, X, and Y codes
Injuries classiﬁ ed by type
(sprain, fracture,
dislocation)
Injuries classiﬁ ed ﬁ rst by site
(wrist, elbow, shoulder)
Codes do not offer
laterality (e.g.,  Colles’
fracture: 813.41)
Codes indicate laterality (e.g.,
Colles’ fracture   Right wrist S52.501
Left wrist S52.502)
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Comparison of ICD-9-CM to ICD-10 —cont’d
ICD-9-CM   ICD-10
New diseases are added
yearly to the anatomic
section
Letter U is reserved for new
diseases of uncertain etiology
Diseases of the nervous
system and sense organs
are in one chapter
Three separate chapters for
diseases of the nervous system
and sense organs:
Diseases of the Nervous System
Diseases of the Eye and Adnexa
Diseases of the Ear and Mastoid
process
Late effects classiﬁ ed
990–995
Late effects of injury or illness
appear at the end of each
anatomic chapter
Appendix of Mental
Disorders
Appendix of Mental and
Behavioral Disorders
Fourth- and ﬁ fth-digit
requirements
Fourth-, ﬁ fth-, and sixth-digit
requirements
Common Diagnosis Codes
Disease   ICD-9-CM   ICD-10
Alzheimer’s disease 331.0  G30.00 early onset
G30.01 late onset
Angina pectoris 413.9  I20.0 unstable I20.1
with spasm
Anorexia nervosa 307.1  F50.0
Appendicitis   540   K35
K35.0 with peritonitis
Asthma, unspeciﬁ ed 493.9x  J45.9
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MED INS
Common Diagnosis Codes —cont’d
Disease   ICD-9-CM   ICD-10
Asthma with COPD 493.20  J44
Attention deﬁ cit disorder 314.00  F90.0
F90.1 with
hyperactivity
Bipolar affective disorder 296.63  F31.0 hypomanic
F31.1 without
psychotic symptoms
Cerebral palsy 343.9   G80.0–G80.9
Cerumen impaction 380.4  H61.2
Congestive heart failure 428.0  I50.0
Conjunctivitis (pinkeye) 372.30  H10.3 acute
H10.4 chronic
Diabetes mellitus 250   E10–E14
Epilepsy   345   G40.0–G40.9
Esophageal reﬂ ux 530.81  K21.9
Esophagitis (reﬂ ux) 530.11  K21.0
Fatigue   780.79  R53
Gastric ulcer 531   K20
Glaucoma   365.9  H40.0–H42.8
Headache   784.0  R51
Human immunodeﬁ ciency
virus (HIV)
042   B20.0–B23. 8
Hyperlipidemia   272.4  E78.0–E78.5
Hypothyroid   244.9  E03.0–E03.9
Infectious mononucleosis 075   B27
Inﬂ uenza 487   J09–avian
J10–other
Continued
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MED INS
Common Diagnosis Codes —cont’d
Disease   ICD-9-CM   ICD-10
Inﬂ uenza with pneumonia 487.0  J10.0
Iron deﬁ ciency anemia 280.9  D50.0–D50.9
Irritable bowel syndrome 564.1  K58.0 w/diarrhea
K58.9 w/o diarrhea
Multiple sclerosis 340   G35
Myalgia, unspeciﬁ ed 729.1  M79.1
Myocardial infarction (heart
attack)
410.9  I21.0–I21.9 initial MI
I22.0–I22.9
subsequent MI
Otitis media, acute serous 381.01  H65.0
Parkinson’s disease 332.0  G20–G22
Poison ivy causing dermatitis 692.6  L23.7
Senile dementia 290.0  F03
Sore throat 462   R07.0
Swimmer’s ear, acute 380.12  H60.0–H60.9
Tinnitus, unspeciﬁ ed 388.30  H93.1
Tonsillitis, acute 463.00  J03.9
Tonsillitis, chronic 474.00  J35.0
Upper respiratory infection 465.9  J00–J06.9
Urinary tract infection 599.0  N39.0
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MED INS
Guidelines for Hypertension Coding
Description   ICD-9-CM   ICD-10
Hypertension, essential,
or NOS
401   I10
Hypertension with heart
disease
402   I11.0 w/heart failure
I11.9 w/o heart failure
Hypertensive renal
disease
403   I12.0 w/renal failure
I12.9 w/o renal failure
Hypertensive heart and
renal disease
404   I13.0–I13.2
Hypertensive
cerebrovascular disease
430–438  I60.0–I60.9 plus code HTN
Hypertensive
retinopathy
401–405  H35.0
Hypertension secondary 405   I15.0–I15.9
Factors Inﬂ uencing Health Status and
Contact With Health Services
Description   ICD-9-CM  ICD-10
Well child visit V20.2   Z00.1
General medical examination adult V70.0   Z00.0
Pre-employment examination V70.5   Z02.1
Sports physical examination V70.3   Z02.5
Blood alcohol and blood drug
testing
V70.4   Z04.0
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MED INS
ICD-10-PCS
The  International Classiﬁ cation of Diseases, 10th edition, Proce-
dure Coding System (ICD-10-PCS) replaces the Procedure section
(volume 3) of the ICD-9-CM. This system contains 7    alphanumeric
characters:

■ Character 1: Section
   ■ 0: Medical procedures
   ■ 1: Obstetrics
   ■ 2: Placement
   ■ 3: Administrative
   ■ 4: Measurement & Monitoring
   ■ 5: Extracorporeal Assistance & Performance
   ■ 6: Extracorporeal Therapies
   ■ 7: Osteopathic
   ■ 8: Other Procedures
   ■ 9: Chiropractic
   ■ B: Imaging
   ■ C: Nuclear Medicine
   ■ D: Radiation Oncology
   ■ F: Physical Rehabilitation & Diagnostic Audiology
   ■ G: Mental Health
   ■ H: Substance Abuse Treatment
   ■ Character 2: Body system
   ■ Character 3: Root operation
   ■ Character 4: Body region
   ■ Character 5: Approach
   ■ Character 6: Device
   ■ Character 7: Qualiﬁ er
   Example : The code for extracapsular cataract extraction with
posterior chamber intraocular lens implantation, left eye, is
08RK O JZ:

■ Character 1 is 0 (medical and surgical).
   ■ Character 2 is 8 (eye).
   ■ Character 3 is R (replacement).
   ■ Character 4 is K (lens, left).
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   ■ Character 5 is O (open).
   ■ Character 6 is J (synthetic substitute).
   ■ Character 7 is Z (no qualiﬁ er).
Coding Websites
■ World Health Organization ICD-10 search page:    http://apps.
who.int/classiﬁ cations/apps/icd/icd10online
   ■ Centers for Medicare and Medicaid Services ICD-9 overview:
  http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/
   ■ American Academy of Professional Coders:    http://www.
aapc.com
Common Diagnostic Codes













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Important Phone and Fax Numbers
Referring Doctors



















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Claims




















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54
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Utilization Review




















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55
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Notes




















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56
OSHA and Standard Precautions
The Occupational Safety and Health Administration (OSHA) has
mandated various standards to ensure the safety of all health
care professionals and their patients, including disposal proce-
dures and cleaning up spills of biohazardous material.
Disposal Procedures
Proper disposal of contaminated articles is an important compo-
nent of OSHA rules.
Biohazard Container
Regular Waste
Container Sharps Container
All supplies
contaminated with
blood or body ﬂ uids,
such as:
• Gloves
• Gauze
• Bandages
• Gowns
• Other contaminated
linens
• Wrappers
• Paper towels
• Examination table
paper
• Supplies not
contaminated with
blood or body
ﬂ uids
• Needles
• Capillary tubes
• Dermal puncture
lancets
• Broken glass or
slides
Safety Tips
■ Do not recap needles.
■ Keep Material Safety Data Sheets (MSDS) on ﬁ le.
■ Clean work area regularly with 10% bleach (1 part bleach to
10 parts H
2 O—for example, add 10 mL bleach to 100 mL
H
2 O).

■ Try to wash hands in front of patients.
■ When unable to wash hands, use hand sanitizer.
■ All exposures must be reported, documented, and followed
up.
■ Anticipate exposure and wear proper personal protective
equipment (PPE).
CLIN/DX
PROC
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■ Refer to OSHA Website for more information (www.osha.
gov).
Steps for Cleaning up a Biohazard Spill
1. Put on gloves and other PPEs.
2. Contain the spill with paper towels.
3. Cover the spill with 10% bleach solution.
4. Cover it with additional paper towels, if needed.
5. Add more bleach, if needed.
6. Let sit at least 20 minutes.
7. Clean up spill with mechanical device.
8. DO NOT use hands.
9. Dispose of all materials in biohazard container.
10. Clean area again with bleach and dispose of all cleaning
materials in biohazard container.
11. Report and document spill using the incident report
supplied by the ofﬁ ce.

Biohazard symbol
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58
CLIN/DX
PROC
Patient Interview and Documentation
Proper interview techniques are essential when obtaining a
patient’s medical history and the reason for the appointment.
The following checklist helps ensure that you obtain all the per-
tinent information.
Interview Checklist
____ 1. Ask, “Why are you here today?” or “What brings you
in today?” (Open-ended questions)
____ 2. Ask, “Can you describe the symptoms?”
____ 3. Ask, “When did you ﬁ rst notice these symptoms?”
____ 4. Ask the patient if he or she has any other symptoms,
such as fever, pain, vomiting/diarrhea, difﬁ culty
breathing, persistent cough, or rash.
____ 5 Ask, “Is there anything that makes the symptoms
worse?”
____ 6. Ask, “Have you experienced any recent injuries?”
____ 7. Ask the patient if he or she has any other medical
problems or illnesses.
____ 8. Ask the patient if he or she has taken any prescription
or OTC medications, vitamins, or supplements to
relieve the symptoms. If so, ask what, when, and how
much.
____ 9. Look for observable signs, such as rash, limp, and
wincing.
____ 10. Look for nonverbal cues.
____ 11. Record information in the patient’s own words
whenever possible.
____ 12. ____________________________________________________
____ 13. ____________________________________________________
____ 14. ____________________________________________________
____ 15. ____________________________________________________
____ 16. ____________________________________________________
____ 17. ____________________________________________________
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CLIN/DX
PROC
Suggested Responses to Patients
■ “I understand that this is a very tough time for you.”
■ “Is there anyone I can call for you?”
■ “Is there anything I can do for you?”
■ “I’ll see if I can help you with that.”
■ “It is recommended that you do it this way.”
■ “Would you like me to repeat the instructions?”
Pain Assessment Checklist
_______ 1. How severe is the pain? (Scale of 1 to10)
_______ 2. Is the pain dull or sharp?
_______ 3. When did you ﬁ rst notice the pain? (Onset)
_______ 4. Did pain come on suddenly?
_______ 5. What were you doing when you ﬁ rst noticed the
pain?
_______ 6. Duration of pain? Constant or intermittent?
_______ 7. Location of pain?
_______ 8. What makes pain worse? (Movement, sitting, and
so forth)
_______ 9. What makes pain better?
_______ 10. Taken anything for pain? If so, what was taken?
(Dosage and frequency of dosage)
_______ 11. Did pain medication ease the pain?
_______ 12. _________________________________________________
_______ 13. _________________________________________________
_______ 14. _________________________________________________
_______ 15. _________________________________________________
_______ 16. _________________________________________________
_______ 17. _________________________________________________
_______ 18. _________________________________________________
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PROC
No pain at all
Moderate pain Worst pain ever
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PROC
Vital Signs
Vital signs are important indicators of body function. Accurate
measurement and documentation of a patient’s vital signs is an
essential skill for medical assistants.
Average Normal Ranges for Vitals
Age
Temp
(°F)
Pulse
(beats/min)
Resp
(breaths/min) BP
Newborn* 97–100 80–160 30–60 74/50–100/70
Child
(1–5 yrs)
98.6 80–130 20–30 80/50–112/80
Child
(6–16 yrs)
98.6 75–110 15–23 80/50–120/80
Adult 97–99 60–100 12–20 90/60–120/80
* Ranges should be used as a reference only. Normal ranges, especially for
newborns and children, can vary.
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Temporal
Carotid
Brachial
Radial
Femoral
Dorsalis
pedis
Posterior
tibial
Popliteal

Pulse points
Vital Signs Basics
Temperature Basics
■ Temperature increases with infection, exercise, crying, and
pregnancy.
■ Temperature is decreased in morning.
■ For rectal temperature, subtract 1 degree.
■ For axillary temperature, add 1 degree.
■ Note method of temperature assessment, such as oral,
rectal, axillary, or aural.
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CLIN/DX
PROC
Pulse Basics
■ Pulse increases with physical activity, pain, anxiety, fever,
pregnancy, and certain medications.
■ Pulse is decreased in elderly and with certain medications.
■ Note pulse rhythm and volume.
Respiration Basics
■ Respiration increases with physical activity, anxiety, certain
medications, and fever.
■ Respiration is decreased in elderly and with certain
medications.
■ Note respiratory rhythm and depth.
■ Note abnormal breath sounds, if any.
■ Take respiration rate without the patient knowing.
Blood Pressure Basics
■ BP increases with physical activity, anxiety, stress, smoking,
and certain medications.
■ BP decreases with certain medications.
■ Make sure cuff is correct size for patient.
■ Never hold bell with thumb.
■ Position cuff so scale is easily visible.
■ Position patient’s arm at heart level and support the arm.
■ Wait 1 to 2 minutes before repeating BP.
■ Note arm (L or R) and patient position (sitting or lying).
Documentation
Proper documentation techniques are essential when recording
patient information. Here are tips to remember when document-
ing entries in a patient’s chart.
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CLIN/DX
PROC
General Charting Guidelines
■ Always use blue or black ink.
■ Chart immediately after procedure is complete.
■ Write legibly.
■ When charting CC, try to use patient’s own words.
■ Begin new entry on new line.
■ Begin entry with date and time.
■ Be accurate and speciﬁ c.
■ Use standard abbreviations.
■ Never erase an entry; correct errors in charting appropriately.
■ Always sign your entry with your name and title.
Charting Examples
11/03/16; 9:00
a.m.
CC: pt c/o sore throat and fever of 102°F
X3 days. Pt states it’s difﬁ cult to swallow.
Took ibuprofen 400 mg q8hr last 2 days.
—————————————C. Chapin, CMA
11/03/16;
9:30 a.m.
Rapid strep: positive.———C. Chapin, CMA
7/17/16; 1:30 p.m. CC: pain and numbness in L leg and foot
for 1 week. Pain worse when sitting or lying.
Patient states a “10” on the pain scale.
Taken ibuprofen 400 mg q6hr with no
relief . No recollection of actual back
injury.———————–——-C. Chapin, CMA
Blank Charting Box

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65
CLIN/DX
PROC
Documenting Using SOAP Method
Many ofﬁ ces use the SOAP method for a more efﬁ cient way of
charting. SOAP stands for:
■ S ubjective patient information, which consists of the
symptoms only the patient can feel.
■ O bjective patient information, which consists of the
observable symptoms, such as a rash, or measurable
ﬁ nding, such as vital signs.

■ A ssessment, which is when the physician forms a diagnosis
based on the subjective and objective information.
■ P lan, which is then formulated by the physician and may
include further laboratory tests or treatments.
Transcription Entry
Stacy James
Date of Birth: 05/11/94
Visit Date: 07/11/15
S: Patient complains of sore throat, swollen glands, and
extremely tired for 5 days.
O: Laboratory results: rapid strep: negative. Upon examination
physician observes splenomegaly temp 100.4°F.
A: Physician orders CBC, Mono Test, and LFT.
P: Bed rest, no physical activity for 6 weeks.
Progress Notes in Patient’s Chart
Progress Notes
Patient Name: James, Stacy D.O.B. 05/11/90
Chart # 739410
Date S O A P
07/11/15 Patient complains of sore throat, swollen glands, and
feeling exhausted for 5 days.
T: 100.4, rapid strep: negative, abdominal exam
reveals splenomegaly.
Order CBC, Mono Test, and LFTs
Bed rest, no physical activity for 6
weeks.
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PROC
Notes

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Assisting With the Physical Examination
1. Wash hands.
2. Prepare examination room.
3. Gather supplies:
a. Gown or drape
b. Gloves
c. Ophthalmoscope
d. Otoscope
e. Percussion hammer
f. Tongue depressors
g. Laboratory supplies, such as sterile container, lancets,
and so forth
4. If routine urinalysis is needed, instruct patient on proper
CVMS collection.
5. Obtain and chart patient’s height and weight.
6. Obtain and chart patient’s vitals.
7. Obtain current medical history and present illness (PI).
Record all pertinent information.
8. Instruct patient regarding disrobing and gowning and
assuming a sitting position.
9. Inform patient that physician will be right in.
10. Assist physician with positioning patient during
examination.
11. Pass supplies and instruments as requested by physician.
12. Perform various tests as requested by physician.
13. Provide patient education as needed.
14. Clean room after patient leaves.
Notes

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68
CLIN/DX
PROC
Positioning Chart
POSITION USE

90˚
angle

Sitting Position
Sitting Examination of head, neck, chest, heart, lungs,
back, and arms.
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69
CLIN/DX
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Supine Position
Supine (Recumbent) Examination of head, neck, chest,
heart, abdomen, legs, and arms.

Prone Position
Prone Examination of back and feet.

Lithotomy Position
Lithotomy Gynecological examination
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70
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PROC

Dorsal Recumbent Position
Dorsal Recumbent Examination of head, neck, chest, and
heart. May be used for gynecological
examination.

45˚
angle

Semi-Fowler’s Position
Semi-
Fowler’s
Examination of head, neck, chest, and heart. For
patients with breathing or back difﬁ culties.
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PROC

Sims’ (left lateral) Position
Sims’ Examination of anal and rectal areas; proctological
procedures.

Knee-Chest Position
Knee-Chest Examination of anal and rectal areas; proctological
procedures.
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General Clinical Ofﬁ ce Tips
Things to do before the ofﬁ ce opens:
_____1. Clean all examination rooms.
_____2. Make up bleach solution.
_____3. Perform quality control on various laboratory equipment.
_____4. Record QC results.
_____5. Record temperatures of refrigerators, freezers, and so
forth.
_____6. Make sure all instruments are in working order, such
as otoscopes, lights, etc.
Things to do before the ofﬁ ce closes:
_____1. Pull charts for following day.
_____2. Pick up examination rooms and empty trash in all areas.
_____3. Wipe down counters, scales, and so forth with bleach
solution.
_____4. Sterilize instruments as needed.
Notes

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73
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PROC
Gynecology and Obstetrics Exams
Gynecology
Supplies
■ ThinPrep container or frosted glass slide
■ Cervical scraper, cytobrush, and/or cotton-tipped applicator
■ Spray ﬁ xative
■ Cytology request form
■ Speculum
■ Gloves
■ Lubricant
■ Examination gown
■ Tissues
■ Slide holder
■ Culture swab, if needed for culture
■ Laboratory requisition slip, if needed for culture
Patient Prep
■ Obtain vitals, weight, and patient history, including last
menstrual period (LMP).
■ Ask patient if she needs to void.
■ Give patient gown or drape and instruct her to remove all
clothing.
■ For breast examination, put patient in supine position.
■ For pelvic examination, put patient in lithotomy position,
with feet in stirrups and buttocks at edge of table.
■ Hand physician supplies as needed.
■ Label all specimens completely and accurately.
■ Complete all required requisition slips.
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74
CLIN/DX
PROC
Wet Prep Procedure for Trichomonas ■ Obtain clean glass slide.
■ Place a drop of saline onto slide.
■ Obtain swab of vaginal discharge.
■ Mix discharge with saline on slide.
■ Cover slip and examine under microscope.

Trichomonas Slide
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75
CLIN/DX
PROC
KOH Prep for Candida ■ Obtain clean glass slide.
■ Obtain swab of vaginal discharge.
■ Place discharge on slide.
■ Add drop of KOH.
■ Apply cover slip to slide and examine under microscope.

Candida Slide
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76
CLIN/DX
PROC
Common Gynecological Infections
Infection Organism Symptoms Diagnosis Treatment
Trichomonas Trichomonas
vaginalis
(protozoa)
Severe itching; profuse,
frothy discharge; odor
Wet prep Flagyl
Candidiasis Candida
albicans (yeast)
Burning and itching,
thick cottage cheese–
like discharge
KOH prep Gyne-Lotrimin,
Monistat, or Diﬂ ucan
Chlamydia Chlamydia
trachomatis
(bacteria)
Can be asymptomatic
in women. Some
symptoms include:
dysuria, vaginal
discharge, genital
itching and/or irritation.
Direct antigen
testing or
DNA probe
testing
Doxycycline,
Zithromax
Gonorrhea Neisseria
gonorrhoeae
(bacteria)
Can be asymptomatic
in women. Some
symptoms include:
yellow vaginal
discharge, dysuria.
Culture or
DNA probe
Ceftriaxone
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77
CLIN/DX
PROC
Obstetrics
Components of First Prenatal Visit
■ Complete medical history, including LMP, obstetric history
■ Calculate due date
■ Full breast, pelvic, abdominal, and rectal examinations
■ Vitals
■ Weight
■ Laboratory tests
■ CBC
■ Urinalysis
■ Rubella
■ RPR
■ Blood type and Rh
■ PAP smear
■ Tests for chlamydia, gonorrhea, and group B beta
streptococcus
■ Hepatitis B and HIV (highly recommended)
■ Patient education
Calculating Due Date
Naegele’s rule
LMP + 7 days – 3 months + 1 year

7 17 2014
37 1
4 24 2015
()
()
LMP
Due date
−+ +
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78
CLIN/DX
PROC
Return Prenatal Visits
■ Vitals and weight
■ Urinalysis, especially protein and glucose
■ Fundal height measurement
■ Fetal heart tones
■ Ultrasound
■ Abdominal and/or transvaginal
■ Patient needs to drink 32 oz H
2 O 1 hr before test
■ Amniocentesis (if indicated)
■ Approx. 15 to 18 weeks
■ >35 yrs old
■ High-risk pregnancy
■ Laboratory tests
■ AFP (approx 15 to 20 weeks)
■ 1 hour GTT (approx 24 to 28 weeks)
■ Chorionic villus sampling
Postpartum Visit
■ Vitals
■ Weight
■ H and H
■ PAP smear
■ Breast and pelvic examinations
■ Discussion of birth control
Pediatrics Exams
Health Maintenance Visits
■ Usual schedule: 1 mo, 2 mo, 4 mo, 6 mo, 9 mo, 12 mo,
15 mo, 18 mo, 2 yr, every year thereafter
■ Weight, length (height), head circumference
■ Complete growth charts
■ Anticipatory guidance
■ BP age 3 and older
■ Laboratory tests, such as PKU, urinalysis, Hgb, cholesterol,
and lead
■ Immunizations
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79
CLIN/DX
PROC
Vaccine
Recommended Immunization Schedule, Birth Through 18 yearsRecommendations in this table are for reference only. Always refer to the full guidelines at www.cdc.gov/vaccines/schedules
Pneumococcal polysaccharide(PPSV23)
1st
dose
1st
dose2nd
dose
1st
dose2nd
dose
3rd
dose
1st
dose2nddose
4th dose
5th
dose(Tdap)
2nd dose
3rd dose
11–12years
7–10years
4–6
years
2–3
years
19 – 23
mos
18
mos
15
mos
12
mos
9
mos
6
mos
4
mos
2
mos
1
mo
Birth
16 –18years
13 –15years
Rotavirus (RV)RV1(2-dose series);RV5 (3-dose series)Hepatitis B (HepB)Haemophilus influenzae
type b

(Hib)Inactivated poliovirus(IPV: <18 yrs) Tetanus, diphtheria, & acellularpertussis (Tdap:

7 yrs)
Influenza (IIV; LAIV)2 doses for someMeasles, mumps, rubella (MMR)Varicella (VAR)Hepatitis A

(HepA)
Human papillomavirus(HPV2: females only; HPV4:males and females)Meningococcal (Hib-MenCY
6 weeks; MenACWY-D

9 mos;
MenACWY-CRM

2 mos)
Pneumococcal conjugate(PCV13) Diphtheria, tetanus, & acellularpertussis (DTaP:<7yrs)
All children Catch-upCertain high-risk groups Not routinely recommended
3rd or
4th dose
1st
dose
1st
dose2nddose2nd
dose
4th dose1st dose
4th
dose2nddose
1st dose
2-dose series
2nddose
(3-dose
series)
1st
dose
Booster
3rd dose
Annual vaccination (IIV only)
Annual vaccination (IIV or LAIV)
3rd
dose
(Source: Centers for Disease Control and Prevention).

Note:
The CDC updates the immunization chart yearly; refer to most current chart for further information.

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80
CLIN/DX
PROC
Sick Child Visits
■ Temperature
■ Blood pressure
■ Weight
■ Signs and symptoms
■ Physician examination
Tips on Working With Infants and Children
■ Carry infant properly.
■ Gain trust of child and parents.
■ Be honest with child; never say “It won’t hurt.”
■ Use language child can understand.
■ Demonstrate procedures with doll or stuffed animal.
■ Be patient with child, use calm tone of voice.
■ Involve children as much as possible in procedure, such as
letting them touch or use stethoscope before using it on them.
■ Help child overcome his or her fears.
■ During well and sick visits, observe for signs of abuse, such
as bruises, burns, or other unexplained injuries.
GI Procedures
Fecal Occult Blood
Patient Prep
■ Patient must follow pretesting instructions and diet
restrictions completely.
■ Emphasize importance of precisely following these
instructions.
■ Patient must follow a high-ﬁ ber, no-red-meat diet for 2 days.
■ Patient should discontinue certain medications that can
interfere with testing.
■ False-positive results can occur with aspirin or iron
supplements.
■ False-negative results can occur with consumption of
vitamin C.
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81
CLIN/DX
PROC
■ Stool specimens should not be collected during
menstruation or while hemorrhoids are bleeding.
■ Show collection kit to patient and explain procedure for
collection of stool specimen.
■ Remind patient to keep occult blood card out of direct
sunlight.
■ Emphasize that three different specimens must be collected
for testing.
■ Once the three sections of the card have been ﬁ lled up,
instruct patient to put the card in the envelope provided in
kit. Emphasize that only this special envelope can be used.

■ Once card has been received by ofﬁ ce, test according to
manufacturer’s speciﬁ cations. Record results in patient’s chart.

Positive and Negative Occult Blood Test Results (From
Strasinger SK, DiLorenzo MS. The Phlebotomy Textbook, 3rd
ed. F.A. Davis, Philadelphia, 2011.)
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82
CLIN/DX
PROC
Patient Prep for Colonoscopy
■ A clear liquid diet the day before examination. Clear liquids
include: broth, JELL-O (not red, purple, or blue), Gatorade/
Powerade (not red, purple, or blue), non-dairy–based orange
or lime sherbet, white grape juice (or any clear juice), plain
tea or coffee, Popsicles (again, no red, purple, or blue).

■ Patient will be instructed to drink a colon cleansing prep the
day before the examination. Common ones are MiraLAX or
Gatorade based. For better drinking results, keep the prep in
the refrigerator. There are also preps in pill form. Make sure
you explain to the patient that not all insurance policies will
pay for the pill preparation, and they should check with their
insurance company before selecting a prep.

■ It is very important to consult the ofﬁ ce protocol regarding
speciﬁ c patient preparation.
Eye and Ear Exams
Visual Acuity Testing for Distance
■ Use Snellen’s eye chart composed of letters, capital E
letters, or pictures.
■ Select proper chart based on age and development of
patient.
■ Explain procedure to patient.
■ Give patient eye occluder and tell patient to hold over
nontested eye and not to close or squint that eye.
■ Have patient stand 20 feet from eye chart.
■ If patient wears glasses or contacts, he or she should wear
them for the examination.
■ Usually test right eye ﬁ rst, then left eye.
■ Have patient start with the 20/70 line and continue down
each line.
■ The number to the side of the smallest line is the patient’s
results for that eye.
■ Repeat with left eye.
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83
CLIN/DX
PROC

1
2
3
4
5
6
7
8
200 FT
61 M
0
10˚
20˚
30˚
40˚
50˚
60˚
70˚
80˚
100
110˚
120˚
130˚
140˚
150˚
160˚
170˚
180˚
90˚
100 FT
30.5 M
70 FT
21.7 M
50 FT
15.2 M
30 FT
9.1 M
20 FT
6.1 M
15 FT
4.6 M
10 FT
3.0 M
20
200
20
100
20
70
20
60
20
30
20
20
20
20
20 FT
6.1 M
20
15
20
10

Rotating “E” Snellen Chart (From Eagle S, Brassington C,
Dailey C, Goretti C. The Professional Medical Assistant. F.A.
Davis, Philadelphia, 2009; 764, with permission.)
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84
CLIN/DX
PROC
Near Visual Acuity Testing
■ Obtain test card.
■ Have patient hold card 14 ″ to 16 ″ away from the eyes.
■ Test both eyes as you would for Snellen’s test.
■ Have patient read out loud each line or paragraph.
■ Note and record smallest line the patient can read
comfortably without squinting or other difﬁ culties.
Ishihara Test for Color Vision

■ Use Ishihara color plates.
■ Test patient using all 14 color plates.
■ Ask patient to identify the numbers formed by the colored
plates.
Interpretation of Results:
Normal color vision = 10 or more plates read correctly
Color vision deﬁ ciency = 7 or fewer plates read correctly
Eye Irrigation
Eye irrigation is used to wash out foreign particles or chemicals
or to apply antiseptic solution.

■ Use proper irrigation solution as prescribed by physician.
■ Warm solution if required.
■ Obtain all supplies needed:
■ Gloves
■ Basin
■ Towel
■ Syringe or bulb
■ Normal saline or other prescribed sterile irrigation solution
■ Put patient in sitting or lying position, with head tilted
toward the affected eye.
■ Place towel on patient’s shoulder.
■ Have patient hold basin to catch ﬂ uid.
■ Fill irrigation syringe or bulb with solution.
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85
CLIN/DX
PROC
■ Hold eye open and carefully direct the stream of irrigant
from the inner to outer canthus of the affected eye, being
careful not to touch the syringe to the eye.
■ Repeat as needed.
Eye Instillation
Eye instillation is used to administer medication or normal saline.
■ Use proper medication as prescribed by physician.
■ Put patient in sitting position, instruct patient to tilt head up
slightly and to look up.
■ If using sterile eyedropper, draw up required amount of
solution needed.
■ Carefully pull down the lower conjunctival sac and instill the
required number of drops into the sac, being careful not to
touch the eye with the dropper.
■ Instruct patient to close eye gently for a few seconds, but to
not squeeze shut.

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86
CLIN/DX
PROC
Ear Irrigation
Ear irrigation is used to clean out wax, a foreign body, or
discharge.
■ Use proper irrigation solution as prescribed by physician.
■ Warm solution if required.
■ Obtain all supplies needed:
■ Gloves
■ Basin
■ Towel
■ Syringe or bulb
■ Normal saline or other prescribed irrigation solution
■ Put patient into the sitting position and place towel on
patient’s shoulder.
■ Have patient hold basin to catch draining ﬂ uid.
■ Have patient tilt head toward the affected ear.
■ Fill syringe with required amount of solution.
■ Gently pull ear upward and backward for an adult and down
and backward for a child.
■ Insert the syringe into the ear and position the ﬂ ow of the
solution toward the roof of the ear canal, never directly
irrigating the tympanic membrane.

■ Reﬁ ll syringe and repeat irrigation as needed.
Ear Instillation
Ear instillation is used to administer medication or normal saline.
■ Use proper medication as prescribed by physician.
■ Place patient in lying position, with affected ear facing up.
■ Gently pull ear upward and outward for adults and
downward and outward for children ages 3 years and
younger.

■ Hold the tip of the dropper to the opening of the ear canal
and instill the prescribed number of drops.
■ Have patient stay in position for 2 to 3 minutes to allow
medication to disperse completely.
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87
CLIN/DX
PROC
Electrocardiography
Chest Lead Placement

123456
V
1
V
2
V
3
V
4
V
5
V
6
Midclavicular
lineAnterior
axillary line
Midaxillary
line
Lead Placement
V 1 4
th
intercostal space to the right of the sternum
V
2 4
th
intercostal space to the left of the sternum
V
3 Halfway between V
2 and V
4
V 4 5
th
intercostal space in the left midclavicular line
V 5 Lateral to V4, in the left anterior axillary line
V
6 Lateral to V5, in the left midaxillary line
NOTE : V
4 , V
5 , and V
6 should be placed along horizontal line, not necessarily
following intercostal space.
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88
CLIN/DX
PROC
Limb Lead Placement
RA and LA—anterior surface of the upper arms
RL and LL—clean, dry, ﬂ eshy areas of the lower legs.
Normal Cardiac Cycle

P-R
segmentP wave
S-T
segment T wave U wave
P-R interval
QRS
complex
Q
wave
S wave
Q-T interval
R

Normal Rhythm Strip

Types of Artifacts
■ Somatic tremor: muscle movement or spasm
■ Electrical interference: ECG machine too close to another
electrical machine or instrument
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89
CLIN/DX
PROC
■ Baseline interruption: lead comes off body or broken lead
■ Wandering baseline: poor skin connection or loose electrode
Basic ECG Procedure
1. Wash hands and assemble supplies.
2. Greet and identify your patient, introduce yourself, and
explain the procedure.
3. Instruct the patient to remove socks or panty hose and
clothing above the waist, including undergarments.
4. Assist the patient as necessary.
5. Position the patient on the examination table in the supine
position. Drape for privacy.
6. Turn on the machine. Enter the patient’s name, date, time,
and patient’s current cardiac medications into the machine
or write the information on the tracing.
7. Clean the patient’s skin with alcohol at each site where an
electrode will be placed and clip hair if necessary.
8. Apply self-adhesive electrodes to a dry, clean, intact, ﬂ eshy
area on the extremities across from one another and to the
cleaned areas on the chest. Connect the lead wires to the
electrodes using the alligator clips. Make sure the correct
leads are connected to the correct electrodes. Do not cross
lead wires.
9. Press the AUTO button on the ECG machine. The machine
runs automatically once the AUTO button is pressed.
Watch for artifacts and make corrections as needed to get
an acceptable tracing.
10. Disconnect the lead wires from the electrodes and then
remove the electrodes from the patient.
11. Assist the patient off of the examination table and with
dressing as needed.
12. Clean and return the ECG machine to storage.
13. Mount the ECG tracing in the patient’s chart or give it to
the physician as directed.
14. Document the procedure in the patient’s chart.
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90
CLIN/DX
PROC
Holter Monitor
Supplies
■ Electrodes
■ Portable tape recorder
■ Holder and belt
Patient Prep
■ If patient is not wearing a shirt that opens in the front, give
him or her a cape and instruct to put on with opening in the
front.

■ Prepare skin before attaching electrodes.
■ Apply electrodes to chest.
■ Tell patient he or she will wear monitor for 24 hours.
Patient Education
■ Instruct patient to:
■ Keep electrodes dry.
■ Keep electrodes in place; do not move them.
■ Keep diary of date, time of day, symptoms, emotional
states, activities, and medications.
■ Activities include but are not limited to walking,
housecleaning, yard work, and sexual activity.
■ Press event marker if any chest pain is experienced but do
not overuse the marker.
■ Do not use electric blanket.
■ Return to ofﬁ ce 24 hours later.
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91
CLIN/DX
PROC
Holter Monitor Lead Placement*

1
3
54
2

# Channel Color Lead Placement
1 1( − ) yellow LA Below left clavicle, just
lateral to the midclavicular
line.
2 2( − ) white RA Below right clavicle, just
lateral to the midclavicular
line.
3 3( − ) blue Sternum At manubrium sterni.
4 3(+) red Mod V4 At the sixth rib on the
midclavicular line.
5 Reference green Reference Lower right chest wall, rib.
Please note, each Holter monitor may be a little bit different and have more or
fewer leads than displayed on this example. Always read the user’s manual
before placing a Holter monitor on a patient.
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92
CLIN/DX
PROC
Spirometry
Patient Prep
■ Stress importance of following instructions exactly.
■ Demonstrate procedure for patient.
■ Position patient according to requirements of the individual
spirometer (seated or standing).
■ If nose clip is required, instruct patient how to apply.
Procedure
■ Program machine with patient’s information.
■ Instruct patient to take a deep breath and then securely
cover mouthpiece with mouth.
■ Tell patient to exhale forcefully into the mouthpiece and not
to stop until you tell him or her.
■ Coach patient while he or she is exhaling.
■ Most spirometers will note if test was adequate. If
inadequate, test must be repeated.
■ Usually three acceptable readings are performed.
Pulse Oximeter
■ Measures patient’s arterial blood oxygen saturation level.
■ Sensor clip is attached to patient’s ﬁ nger, toe, or ear.
■ Used on patients with pneumonia, CHF, COPD, emphysema,
asthma, etc.
■ Movement, ﬁ ngernail polish, weak pulse can affect accuracy.
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93
CLIN/DX
PROC
Notes

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94
CLIN/DX
PROC
Notes

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95
CLIN/DX
PROC
Notes

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96
Adult Immunization Schedule

Age Group
Recommended Immunization Schedule, Adults
Recommendations in this table are for reference only. Always refer to the full guidelines at www.cdc.gov/vaccines/schedules*Covered by the Vaccine Injury Compensation Program
Zoster
1 dose annually
Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 yrs
2 doses
3 doses
1 dose
1 or 2 doses
1 dose
1 or 3 doses
1 or more doses
2 doses3 doses
1 dose
1 or 2 doses
3 doses

65 years60-64 years50-59 years27-49 years22-26 years19-21 years
Influenza
Tetanus, diphtheria,
pertussis (Td/Tdap)
Human papillomavirus
(HPV) Female
Measles, mumps, rubella (MMR)Pneumococcal 13-valent
conjugate (PCV13)
Pneumococcal
polysaccharide (PPSV23)
Meningococcal
Hepatitis A
Hepatitis BHaemophilus influenzae
type b (Hib) Human papillomavirus
(HPV) Male
Varicella
All individuals
Persons with one or more risk factors
No recommendation
Vaccine
PATIENT
ED
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97
PATIENT
ED
Indication
Zoster
1 dose IIV annually
1 dose
1 dose
1 or 2 doses
2 doses
ContraindicatedContraindicatedContraindicated
Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 yrs
3 doses through
age 26 yrs3 doses through age 26 yrs
3 doses through age 26 yrs
3 doses through age 26 yrs
1 dose IIV annually
1 dose IIV or
LAIV annually
1 dose
Tdap each
pregnancy
Heart or
chronic lung
disease,
chronic
alcoholism
Chronic
liver
disease
Health
care
personnel
Certain
blood
disorders
Certain
serious
kidney
conditions
Male-to-
male sex
< 200
cells/µL
≥ 200
cells/µL
HIV infectionImmuno-
compromised
(except HIV)
Pregnancy Diabetes
Influenza
Tetanus, diphtheria,
pertussis (Td/Tdap)
Human papillomavirus
(HPV) FemaleMeasles, mumps, rubella (MMR)Pneumococcal 13-valent
conjugate (PCV13)
Pneumococcal
polysaccharide (PPSV23)
Meningococcal
Hepatitis A
Hepatitis BHaemophilus influenzae
type b (Hib) Human papillomavirus
(HPV) Male
Varicella
1 or 3 doses
1 or 2 doses
1 or more doses
2 doses3 doses
post-HSCT
recipients only
Recommended Immunization Schedule, Adults with Selected ConditionsRecommendations in this table are for reference only. Always refer to the full guidelines at www.cdc.gov/vaccines/schedules*Covered by the Vacci ne Inj ury Compensati on Program
All individuals
Persons with one or more risk factors
No recommendation
Vaccine
Note:
The CDC updates the immunization chart yearly; refer to most current chart for further information. (Data from the
Centers for Disease Control and Prevention)
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98
PATIENT
ED
Travel Immunizations
■ Different countries have different immunization
requirements.
■ Before traveling, patients should check the CDC Website for
information on travel immunizations.
■ CDC source: http://www.cdc.gov/travel/destinations/list
Handwashing
When to Wash Hands
■ Before, during, and after preparing food
■ Before eating food
■ Before and after caring for someone who is sick
■ Before and after treating a cut or wound
■ After using the toilet
■ After changing diapers or cleaning up a child who has used
the toilet
■ After blowing your nose, coughing, or sneezing
■ After touching an animal, animal feed, or animal waste
■ After handling pet food or pet treats
■ After touching garbage
How to Wash Hands
■ Wet your hands with clean, running water (warm or cold),
turn off the tap, and apply soap.
■ Lather your hands by rubbing them together with the soap.
Be sure to lather the backs of your hands, between your
ﬁ ngers, and under your nails.

■ Scrub your hands for at least 20 seconds. Need a timer?
Hum the “Happy Birthday” song from beginning to end
twice.

■ Rinse your hands well under clean, running water.
■ Dry your hands using a clean towel or air-dry them.
Source: Centers for Disease Control and Prevention (http://www.
cdc.gov/handwashing/when-how-handwashing.html)
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Healthy Eating and Nutrition
Food Sources
Simple
Carbohydrates—
Monosaccharides
Simple
Carbohydrates—
Disaccharides Starches
Insoluble
Fiber Soluble Fiber Proteins
Fats
(essential
fatty
acids)
Sugars such as
glucose, fructose,
and galactose.
Foods containing
these include:
fruit (fructose).
High fructose
corn syrup is
added to many
foods.
Sucrose—
granulated
sugar, sugar
beets, honey,
and maple syrup
Lactose—milk
and dairy
products
Maltose—beer
Wheat,
rice,
potatoes,
beans
and peas
Whole
wheat
breads,
oatmeal,
lentils
and black
beans,
cabbage,
onions,
bell
peppers,
corn,
lettuce,
grapes,
dried
fruits
Strawberries,
apples,
carrots, jams,
oats,
legumes,
barley,
ﬂ axseed and
kelp, peanuts,
peas,
mangos,
oranges,
grapefruit,
apricots,
Brussels
sprouts,
turnips, sweet
potatoes
Pecans,
cashews,
sunﬂ ower
seeds,
almonds,
eggs, lean
meats,
cheddar
cheese,
tuna,
salmon,
cod,
haddock
Corn,
safﬂ ower,
soybean,
canola,
olive,
ﬂ axseed
oils
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ED
Calculating Body Mass Index (BMI)
BMI
Body weight in pounds
Height in inches
=×
2
703
Example : A patient weighs 193 lb and is 5 ′ 10 ″ tall.

193
70
703 27 7
2
×= .

BMI and Weight Status
BMI Weight Status
<18.5 Underweight
18.5 to 24.9 Normal weight
25 to 29.9 Overweight
≥ 30 Obese
Thus, the patient in the example above with a BMI of 27.7 is
considered overweight.
Patient Education for Nutrition and BMI
Centers for Disease Control and Prevention:
http://www.cdc.gov/nutrition/everyone/index.html
http://www.cdc.gov/healthyweight/assessing/bmi/index.html
National Institute of Health—BMI guidelines:
http://www.nhlbi.nih.gov/guidelines/obesity/BMI/bmicalc.htm
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PATIENT
ED
MyPlate

MyPlate
(Source: USDA Center for Nutrition Policy and Promotion,
www.choosemyplate.gov)
Glycemic Index
Glycemic Index: Foods on the glycemic index diet are scored on
a scale of 0 to 100 based on how much they raise your blood
sugar level.
Glycemic Load: Describes the quality (glycemic index) and quan-
tity of carbohydrate in foods.
Formula:
Glycemic index × Carbohydrates (grams) / 100 = Glycemic load
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PATIENT
ED
Low GI Medium GI High GI
0–55 56–69 70 or greater
Glycemic Information for Common Foods
Food
Glycemic
Index (GI)
Serving Size
(grams)
Glycemic
Load (GL)
Pasta/Grains
Spaghetti 58 180 26
Fettucini 32 180 15
White rice 89 150 43
Brown rice 50 150 16
Quinoa 53 150 13
Breads
Bagel 72 70 25
White bread 73 30 10
Whole-grain bread 51 30 7
Vegetables
Peas 51 80 4
Carrots 35 80 2
Sweet potato 69 150 22
Baked potato 111 150 33
Tomato 38 123 1.5
Spinach 0 30 0
Corn 55 166 62
Dairy
Ice cream 57 50 6
Milk, full fat 41 250 mL 5
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PATIENT
ED
Glycemic Information for
Common Foods —cont’d
Food
Glycemic
Index (GI)
Serving Size
(grams)
Glycemic
Load (GL)
Milk, skim 32 250 mL 4
Low-fat yogurt (with fruit) 33 200 11
Legumes & Nuts
Black beans 30 150 7
Baked beans 40 150 6
Chickpeas 10 150 3
Kidney beans 29 150 7
Lentils 29 150 5
Cashews 27 50 3
Peanuts 7 50 0
Sugars
Honey 87 2 tsp 18
Sucrose 68 2 tsp 7
Fruits
Apple 37 120 6
Banana 62 120 16
Orange 40 120 4
Grapefruit 25 120 3
Pear 38 120 4
Watermelon 72 152 8
Snacks
Potato chips 51 50 12
Graham crackers 74 25 14
Peanut M&Ms 33 30 6
Continued
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PATIENT
ED
Glycemic Information for
Common Foods —cont’d
Food
Glycemic
Index (GI)
Serving Size
(grams)
Glycemic
Load (GL)
Corn chips 42 50 11
Snickers bar* 51 60 18
Beverages
Orange juice 46 26 (1 cup) 13
Gatorade 78 15 (1 cup) 12
Cola 63 26 (1 cup) 16
Calorie Counter Websites and Apps

■ MyFitness Pal: http://www.myﬁ tnesspal.com/
■ Counting Calories: http://caloriecount.about.com/
■ Calorie Counter: http://www.thecaloriecounter.com/
Health & Food Apps
■ MyFitness Pal
■ SlimKicker Calorie Counter
■ Fast Food Calorie Counter
Pedometer and Exercise Apps
■ Pacer
■ MyMap Walk
■ Runtastic Pedometer
■ Fitness Buddy
■ Daily WorkoutFitStar
■ Runtastic GPS
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PATIENT
ED
Anatomical Charts
Use the following diagrams to educate your patients.
Body Planes

Frontal (coronal) plane
Median (midsagittal) plane
Horizontal (transverse) plane
Superior
Inferior
Posterior
Anterior
Lateral
Medial

Planes of the Body. Left, Saggital plane divides the body into
right and left sections. Middle, Transverse plane divides the
body into upper and lower sections. Right, Coronal plane
divides the body into anterior and posterior positions.
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PATIENT
ED
Abdomen

Mouth and
salivary glands
Bolus of food
Esophagus
Liver
Gallbladder
Right and left
hepatic ducts
Common bile duct
Duodenum
Ascending colon Descending colon
Ileum
Cecum
Stomach
Pancreas
Jejunum
Transverse colon
Sigmoid colon
RectumAnus

Gastrointestinal System. (From Eagle S, Brassington C, Dailey
C, Goretti C. The Professional Medical Assistant: An Integrative
Teamwork-Based Approach. F.A. Davis, Philadelphia, 2009.)
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PATIENT
ED
Heart

Pulmonary artery
Pulmonary artery
Pulmonary veinsPulmonary veins
Superior vena cava
Inferior vena cava
Aorta
Right atrium
Right ventricle
Left atrium
Left ventricle
Interventricular septum
Apex
Mitral valve
Aortic valveTricuspid valve
Pulmonary valve

The Heart. (From Eagle S, Brassington C, Dailey C, Goretti C.
The Professional Medical Assistant: An Integrative Teamwork-
Based Approach. F.A. Davis, Philadelphia, 2009.)
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PATIENT
ED
Lungs

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PATIENT
ED

Top , Nebulizer. Middle, MDI. Bottom, MDI with spacer. (From
Eagle S, Brassington C, Dailey C, Goretti C. The Professional
Medical Assistant: An Integrative Teamwork-Based Approach.
F.A. Davis, Philadelphia, 2009.)
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PATIENT
ED
Endocrine System

Pineal gland
Heart
Thymus gland
Kidney Pancreas
Fat
Testes (2)
in males
Adrenal (suprarenal)
glands (2) Stomach
Thyroid gland
Parathyroid glands (4)
Pituitary (hypophysis) gland
Hypothalamus
Ovaries (2)
in females

Endocrine System. (From Eagle S, Brassington C, Dailey C,
Goretti C. The Professional Medical Assistant: An Integrative
Teamwork-Based Approach. F.A. Davis, Philadelphia, 2009.)
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PATIENT
ED
Urinary System

Right kidney
Left kidney
Ureter
Ureter
Bladder
Urethra

Urinary System. (From Eagle S, Brassington C, Dailey C,
Goretti C. The Professional Medical Assistant: An Integrative
Teamwork-Based Approach. F.A. Davis, Philadelphia, 2009.)
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PATIENT
ED
Skeleton

Cranium
Face
Skull
Thorax
Pelvic girdle
Mandible
Sternum
Ribs
Clavicle
Scapula
Humerus
Xyphoid
process
Ulna
Radius
Carpals
Metacarpals
Phalanges
Phalanges
Ilium
Sacrum
Coccyx
Femur
Patella
Fibula
Tibia
Tarsals
Calcaneus
Metatarsals
Pubis
Ischium
Manubrium

Skeletal System. (From Eagle S, Brassington C, Dailey C,
Goretti C. The Professional Medical Assistant: An Integrative
Teamwork-Based Approach. F.A. Davis, Philadelphia, 2009.)
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PATIENT
ED
Eye

Conjunctiva
ConjunctivaCiliary body
Iris
Cornea
Pupil
Lens
Suspensory
ligaments
Suspensory ligaments
Sclera
Retina
Optic nerve
Anterior
chamber
Optic disc
Choroid
Zonules

Structure of the Eye. (From Eagle S, Brassington C, Dailey C,
Goretti C. The Professional Medical Assistant: An Integrative
Teamwork-Based Approach. F.A. Davis, Philadelphia, 2009.)
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PATIENT
ED
Ear
AuricleExternalauditorycanal
Tympanic
membrane
Stapes
Malleus
Incus
Semicircular
canals
Cochlear andvestibular branch
Cochlea containingorgan of Corti
Oval window
Round window
Eustachian tube
Labyrinth

Structure of the Ear. (From Eagle S, Brassington C, Dailey C, Goretti C.
The Professional
Medical Assistant: An Integrative Teamwork-Based Approach.
F.A. Davis, Philadelphia, 2009.)
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PATIENT
ED
Nose & Throat

Sphenoid
sinus
Frontal
sinus
Superior
nasal concha
Middle
nasal concha
Inferior
nasal concha
Hard palate
Tongue
Epiglottis
Trachea
Nasopharynx
Soft palate
Palantine tonsil
Oropharynx
Laryngopharynx
Esophagus

Structures of the Nose and Throat. (From Eagle S, Brassington
C, Dailey C, Goretti C. The Professional Medical Assistant: An
Integrative Teamwork-Based Approach. F.A. Davis,
Philadelphia, 2009.)
Teaching CPR/First Aid
The American Heart Association uses the acronym CAB—circula-
tion, airway, breathing—to help people remember the order in
which to perform the steps of CPR.
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PATIENT
ED
American Heart Association also advises:
■ If you’re not trained in CPR, then provide hands-only CPR.
That means uninterrupted chest compressions of about 100
a minute until paramedics arrive (described in more detail
below). You don’t need to try rescue breathing.

■ If you’re well trained and conﬁ dent in your ability, begin
with chest compressions instead of ﬁ rst checking the airway
and doing rescue breathing. Start CPR with 30 chest
compressions before checking the airway and giving rescue
breaths.

■ If you’ve previously received CPR training but you’re not
conﬁ dent in your abilities, then just do chest compressions
at a rate of about 100 a minute.
To ﬁ nd a CPR and ﬁ rst aid class locally at the American Red Cross,
go to: http://www.redcross.org/take-a-class/program-highlights/
cpr-ﬁ rst-aid

COMPRESSIONS
Push at least 2 inches on
adult breastbone, 100 times per
minute, to move oxygenated blood
to vital organs.
C
A
B
AIRWAY
Open the airway and check for
breathing or blockage; watch for rise
of chest and listen for air movement.
BREATHING
Tilt chin back for the unobstructed
passing of air; give two breaths and
resume chest compressions.

CPR is as easy as C-A-B (Source: American Heart Association,
www.heart.org )
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PATIENT
ED
Donating Blood
For patients who are physically able and willing to donate:
http://www.redcross.org/blood
Donating Bone Marrow
Registry for bone marrow and cord blood:
http://bethematch.org/Support-the-Cause/
Proper Lifting
1. Stand as close to the item as possible.
2. Tighten stomach muscles and tuck the pelvis.
3. Bend the knees rather than the back, keeping feet
shoulder-width apart.
4. Firmly grasp the item and hug it as close to the body as
possible.
5. Keeping the back as straight as possible, lift by straightening
the knees.
6. Consciously use the leg muscles, rather than the back
muscles, to do the work of lifting.
7. Move the feet in the direction of the lift but do not twist.
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PATIENT
ED

Proper Lifting Technique. (From Eagle S, Brassington C, Dailey
C, Goretti C. The Professional Medical Assistant: An Integrative
Teamwork-Based Approach. F.A. Davis, Philadelphia, 2009.)
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PATIENT
ED
Useful Websites
http://lpi.oregonstate.edu/infocenter/foods/grains/gigl.html
http://www.health.harvard.edu/newsweek/Glycemic_index_and_
glycemic_load_for_100_foods.htm
http://www.alsearsmd.com/glycemic-index/
http://www.cdc.gov/handwashing/
Notes

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120
Routine Venipuncture
Supplies
■ Gloves
■ Tourniquet
■ Antiseptic pads
■ Needles
■ Tubes
■ Adapter
■ Bandage
Steps Involved in Venipuncture
■ Review requisition slip.
■ Greet and identify the patient.
■ Reassure patient and explain procedure.
■ Wash hands and apply gloves.
■ Apply tourniquet, select vein, release tourniquet.
■ Gather and assemble supplies.
■ Clean site and reapply tourniquet.
■ Conﬁ rm puncture site.
■ Remove cap from needle and examine needle.
■ Advise patient that he or she will feel the needle stick the
skin.
■ Anchor vein and insert needle at a 15- to 30-degree angle.
■ Push tube completely into adapter.
■ Remove tube after it is completely ﬁ lled and insert next
tube, if needed. Gently invert tubes.
■ Release tourniquet before last tube is ﬁ lled.
■ Remove tube and gently invert.
■ Remove needle and place gauze over puncture site.
■ Dispose of needle and label tubes.
■ Bandage patient’s arm and release patient.
■ Dispose of used supplies and remove gloves.
■ Wash hands.
■ Properly handle and transport specimens.
LABS
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121
LABS

Cephalic vein
Median cubital
vein Basilic vein
Basilic vein
Median vein

Arm Veins and Three Common Sites for Venipuncture
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122
LABS
ORDER OF DRAW FOR BLOOD TUBES
1. Yellow—Blood culture tube
2. Light blue—Coagulation tube
3. Red—Serum tube without clot activator and gel
4. Gold or Red/Gray—Serum tube with clot activator and gel
5. Green—Heparin tube with or without gel plasma separator
6. Lavender—EDTA tube with or without gel separator
7. Gray—Glycolytic inhibitor
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123
LABS
Tube Colors

© 2005 Becton, Dickinson and Company.
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124
LABS
Dermal Puncture Procedure
Supplies
■ Skin puncture device
■ Microsample collection containers
■ Gauze
■ Antiseptic pads
■ Glass slides
■ Heel warmer
Steps Involved in Dermal Puncture
■ Review requisition slip.
■ Greet and identify patient.
■ Reassure patient and explain procedure.
■ Wash hands and apply gloves.
■ Organize equipment and supplies.
■ Position patient.
■ Select puncture site.
■ Warm puncture site if necessary.
■ Cleanse and dry site.
■ Perform puncture.
■ Wipe away ﬁ rst drop of blood.
■ Make blood smears if requested.
■ Collect hematology specimen then other specimens.
■ Mix specimens if necessary.
■ Apply pressure.
■ Dispose of puncture device.
■ Label specimens.
■ Examine puncture site for stoppage of bleeding.
■ Thank patient and/or parents.
■ Dispose of used supplies and remove gloves.
■ Wash hands.
■ Properly handle and transport specimens
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125
LABS
Common Dermal Puncture Sites

NO
(white area)
YES NO
FINGER PUNCTURE SITES
Calcaneous
(heel bone)
Puncture zone
HEEL PUNCTURE SITES

Finger and Heel Puncture Sites
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126
LABS
Commonly Waived CLIA Test Kits
and Analyzers
Test Kits*
■ Urine hCG by visual color comparison (various manufacturers)
■ Urine qualitative dipstick (various manufacturers)
■ Vaginal pH (various manufacturers)
■ Follicle-stimulating hormone (FSH) female fertility test
■ Ovulation test (LH) by visual color comparison (various
manufacturers)
■ Amedica Biotech Drug Screen Cup
■ Aventir Biotech LLC Home Check Multiple Drug Cup
■ Fecal occult blood (various manufacturers)
■ Glucose monitoring devices (FDA Cleared/Home Use;
various manufacturers)
■ Roche Diagnostic Accutrend Plus System for glucose and
cholesterol testing
■ Rapid Helicobacter pylori antibody test (various
manufacturers)
■ Rapid streptococcal group A (various manufacturers)
■ Rapid inﬂ uenza A/B (various manufacturers)
■ Rapid R.S.V. (various manufacturers)
■ Infectious mononucleosis antibodies (various manufacturers)
Analyzers*
■ Cholestech LDX (lipid panel and liver function tests (LFTs) )
■ Abaxis Piccolo Blood Chemistry Analyzer
■ Siemens DCA 2000 Analyzer (glycolated Hgb, total)
■ Abbott i-STAT handheld analyzer Chem 8+ test cartridge and
hemoglobin and hematocrit cartridges
■ Arkray SPOTCHEM EZ chemistry analyzer (LFTs)
■ HemoCue Hb 201 System
* This is only a partial list of test kits, analyzers, and manufacturers of
CLIA-waived tests. For the most current list of CLIA-waived speciﬁ c manu-
facturer’s test kits, please refer to http://www.accessdata.fda.gov/scripts/
cdrh/cfdocs/cfclia/testswaived.cfm
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127
LABS
Common Lab Tests and Normal Values*
Hematology and Coagulation Normal Range
RBC-male 4.7 to 6.1 × 10 cells/ μ L (10
6
)
RBC-female 4.2 to 5.4 × 10 cells/ μ L (10
6
)
Hgb-male 14.0 to 18.0 g/dL
Hgb-female 12 to 16 g/dL
Hct-male 42% to 52%
Hct-female 37% to 47%
WBC (total) 4.8 to 10.8 × 10 cells/ μ l (10
3
)
Differential:
Neutrophils 53% to 79%
Monocytes 3% to 9%
Eosinophils 0% to 4%
Basophils 0% to 1%
Platelets 130,000 to 400,000/ μ L
ESR
Male <15 mm/hr
Female <20 mm/hr
PT 11.0 to 14.5 sec
PTT 24 to 36 sec
INR 2.0 to 3.0
Bleeding Time Up to 10 minutes
General Chemistry Normal Range
Albumin 3.5 to 5.0 g/dL
Alkaline Phosphatase 31 to 97 U/L
ALT/SGPT 10 to 40 U/L
AST/SGOT 10 to 37 U/L
Continued
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128
LABS
Common Lab Tests and Normal
Values—cont’d
General Chemistry Normal Range
Ammonia 10 to 65 μ mol/L
Amylase 25 to 125 U/L
Bilirubin, total 0.1 to 1.0 mg/gL
BUN 6 to 19 mg/dL
Calcium 8.4 to 10.2 mg/dL
Cholesterol 0 to 200 mg/dL
Cortisol 6 to − 23 μ g/dL
Creatinine 0.5 to 14 mg/dL
Creatine kinase (CPK)
Male 38 to 174 U/L
Female 96 to 140 U/L
CPK-MB <4.0 ng/mL
GGT 5 to 85 U/L
CRP (high-sensitivity assay) 0.2 to 8.0 mg/L
Glucose 70 to 110 mg/dL
Iron 35 to 150 μ g/dL
Hemoglobin A1C 4% to 6%
Lipase 7 to 58 U/L
LDH 91 to 180 U/L
Lithium 0.6 to 1.2 mmol/L
Magnesium 1.6 to 2.6 mg/dL
Phosphorus 2.7 to 4.5 mg/dL
PSA 0 to 4.0 ng/mL
Total protein 6.0 to 8.3 g/dL
Uric acid 2.6 to 7.2 mg/dL
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129
LABS
Common Lab Tests and Normal
Values—cont’d
Electrolytes Normal Range
Sodium (Na+) 135 to 145 mmol/L
Potassium (K+) 3.5 to 5.0 mmol/L
Chloride (Cl − ) 101 to 110 mmol/L
Carbon dioxide (CO
2 ) 22.0 to 30.0 mmol/L
Lipid Proﬁ le Normal Range
Triglyceride 35 to 160 mg/dL
Cholesterol <200 mg/dL
HDL 35 to 60 mg/dL
LDL <130 mg/dL
Thyroid Panel Normal Range
T
3 uptake 32% to 48.4%
T
4 6.1 to 12.2 μg/dL
TSH 0.34 to 5.6 μIU/mL
Thyroglobulin 0 to 56 mg/mL
Urinalysis Normal Range
Color/Clarity Yellow-straw/clear
Odor Aromatic
Speciﬁ c gravity (SG) 1.002 to 1.040
PH 4.5 to 8.0
Glucose Negative
Protein Negative
Leukocytes Negative
Nitrites Negative
Erythrocytes Negative
Bilirubin Negative
Urobilinogen 0.2 to 1.0
Ketones Negative
*Average ranges . Please note: Normal ranges can change based on treatment or
prevention of various disorders and geographical location.
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130
LABS
Collecting and Handling Specimens
CVMS
■ Give patient antiseptic wipe and sterile collection container.
■ Instruct patient to wipe external genitalia with antiseptic
wipe.
■ Next, instruct patient to void a little into the toilet and then
to collect the midstream urine into the container.
■ Have patient ﬁ nish voiding into the toilet.
■ Have patient securely put cover on the container.
■ Label container with patient’s name, date, and time of
specimen.
Stool Collection for Parasitic or
Bacterial Infection

■ Usually requires three fresh specimens collected on 3
different days.
■ Instruct patient to deliver to laboratory within 1 hour of
collection.
■ Stool collection kit may contain two or more containers.
Explain to patient that ONE stool specimen must be divided
and put into all containers.

■ If patient is still in diapers, may recommend that parent line
diaper with plastic wrap and then transfer the specimen into
container without the plastic wrap.
Sputum Collection
■ Give patient sterile container.
■ Instruct patient to cough deeply and expectorate directly into
specimen cup, avoiding contamination.
■ Explain to patient not to “spit” into container.
■ Explain to patient the correct specimen is not saliva but
lower respiratory secretions.
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131
LABS
Throat Culture Collection
■ Gather Culturette swab and tongue depressor.
■ Put on gloves.
■ Have patient sit upright.
■ Instruct patient to open mouth wide and say “AHHH.”
■ Remove sterile, cotton-tipped swab from Culturette tube.
■ Depress patient’s tongue with depressor.
■ Swab area of back of throat on both sides.
■ Be careful not to touch swab to tongue or inside of cheek.
■ Place swab in Culturette tube. Label specimen.
Specimen Collection Do’s and Don’ts
■ Always use sterile container or collection equipment.
■ Always label specimen with patient’s name, date, and type
of specimen.
■ Never label container’s lid.
■ Document procedure in patient’s chart.
■ If patient is collecting specimen at home, make sure patient
understands instructions.
■ Package specimen appropriately and according to OSHA
standards.
■ If specimen is going to an outside laboratory, make sure a
completed requisition form accompanies specimen.
■ If in doubt about how to collect a specimen, always call
laboratory for speciﬁ c instructions.
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132
LABS
Notes

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133
LABS
Notes

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134
Conversion Tables
Dry
Metric Apothecary Household
60 mg 1 gr
1 g 15 gr 1/4 tsp
15 g 4 dr 1 tbsp (3 tsp)
30 g 1 oz 1 oz (tbsp)
12 oz 1 lb (16 oz)
1 kg 2.2 lb
Liquid
Metric Apothecary Household
1 m 1 gt
1 mL (1 cubic centimeter) 15 m 15 gtt
5 mL 1 ﬂ dr 1 tsp
15 mL 4 ﬂ dr 1 tbsp (3 tsp)
30 mL 1 oz (8 ﬂ dr) 1 ﬂ oz (2 tbsp)
500 mL (1 pt) (1 pt or 2 cups)
1,000 mL (1 qt or 2 pts) 4 cups (1 qt)
Length
Metric U.S. Customary
2.5 cm 1 in.
1 m 39.37 in.
MEDS
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135
MEDS
Dosage Calculations
Oral Medications

Dose ordered
Dose on hand
Amount to give=
Example: Physician orders 50 mg of medication, and there are
25-mg tablets on hand.

50
25
2
mg
mg
tablets=
Intravenous (IV) Flow Rate

V volume in mL
T time in minutes
calibration drop factor* g()
()
× ()
tttrate gtt
min min
=

1 000
8
125
,mL
hours
mL/hour=

125
60
15 31mL drop factor gtt gtt
min
()
min min
×=
* Drop factor is identiﬁ ed on the package that contains the tubing.
Example: Physician orders 1,000 mL of dextrose 5% in H
2 O to be adminis-
tered in 8 hours.
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136
MEDS
Seven Rights of Medication Administra tion
“Step 6” from Eagle S, Brassington C, Dailey C, Goretti C. The
Professional Medical Assistant. Philadelphia: F.A. Davis, 2009;
844, with permission.

1 23
4 5
6 7

1. Right drug
2. Right patient
3. Right dosage
4. Right route
5. Right time
6. Right technique
7. Right documentation
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137
MEDS
Injections
Intramuscular (IM) Injection Sites
Courtesy of Tracey Hopkins. MedSurg Notes. 3rd edition.
Philadelphia: F.A. Davis, 2011.
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138
MEDS
Intradermal (ID), Subcutaneous (SC), and
Intramuscular (IM) Injections

Courtesy of Tracey Hopkins. MedSurg Notes, 3rd edition.
Philadelphia: F.A. Davis, 2011.
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139
MEDS
Subcutaneous Injection Sites, Technique,
and Variations

Two inches away
from the umbilicus

Courtesy of Tracey Hopkins. MedSurg Notes. 3rd edition.
Philadelphia: F.A. Davis, 2011.
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140
MEDS
Drugs
Classiﬁ cation of Drugs and Their Endings
Classiﬁ cation
Common Drug
Ending Example
ACE inhibitors -pril benazepril
Antianxiety drugs -lam alprazolam
-pam diazepam
Antibiotics -cillin penicillin
-mycin erythromycin
-cycline tetracycline
-oxacin ciproﬂ oxacin
Antidiabetics -gliptin sitagliptin
Antihyperlipidemics -statin lovastatin
Antiviral -vir acyclovir
Beta blockers -olol propranolol
Calcium channel blockers -dipine amlodipine
Diuretics -mide acetazolamide
-zide hydrochlorothiazide
Local anesthetics -caine novocaine
Opioid analgesics -done primidone
Oral contraceptives -diol estradiol
Proton pump inhibitor -oprazole esomeprazole
Steroids -sone cortisone
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141
MEDS
Food–Drug Interactions
Food Drug Interaction
Any food Amoxicillin Decreased
absorption
Ampicillin
Aspirin
Erythromycin
Levodopa
Methotrexate
Phenobarbital
Tetracycline
Dietary fats Diazepam Increased absorption
Phenytoin
Diets rich in
vitamin K (foods
such as broccoli,
liver, beans, rice,
pork, and ﬁ sh)
Warfarin (Coumadin) Antagonistic effect
Grapefruit juice Cyclosporine Increased absorption
Caffeine Prolonged caffeine
half-life
Warfarin (Coumadin) Delayed excretion of
hydroxycoumarin
Lovastatin Increased lovastatin
and metabolite
concentrations
Quinidine Delayed absorption;
inhibited metabolism
of quinidine
Continued
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142
MEDS
Food–Drug Interactions —cont’d
Food Drug Interaction
High-fat meal Digoxin Decreased
absorption
Warfarin (Coumadin)
High-ﬁ ber meal Digoxin Decreased
absorption
Lovastatin
High-pectin
foods
Acetaminophen Delayed absorption
High-protein diet Levodopa Decreased
absorption
Iron Methyldopa Decreased
absorption
Prescription Requirements for
Controlled Substances
Drug Verbal Orders Written Rx Reﬁ lls
Schedule II No Yes No
Schedule III Yes Yes 5× or 6 months
Schedule IV Yes Yes 5× or 6 months
Schedule V Yes Yes Yes
NOTE: Schedule I drugs are not for medicinal use.
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143
MEDS
Emergency Drugs
■ Adrenalin or epinephrine: Vasoconstrictor that relieves
anaphylactic shock.
■ Albuterol: Bronchodilator that facilitates mucus drainage.
■ Aminophylline: Bronchodilator used to relax the muscles of
the respiratory tract.
■ Chlorothiazide (Diuril): Diuretic used to increase urinary
excretion.
■ Dextrose: Used to counteract hyperinsulinemia and
hypoglycemia.
■ Diazepam: Benzodiazepine that is the drug of choice to treat
status epilepticus and also used as an antianxiety agent and
muscle relaxant.

■ Digoxin: Cardiac glycoside used to slow and strengthen
heartbeat to treat heart failure and arrhythmia.
■ Diphenhydramine (Benadryl): Antihistamine used to relieve
allergic symptoms.
■ Hydrocortisone: Steroid anti-inﬂ ammatory used to suppress
swelling and shock.
■ Naloxone (Narcan): Opioid receptor antagonist used as an
antidote for opiate overdose.
■ Nitroglycerin: Vasodilator used to treat angina pectoris.
■ Phenytoin (Dilantin): Anticonvulsant used for tonic-clonic
seizures, psychomotor and nonepileptic seizures, head
trauma, and Reye’s syndrome.

■ Prochlorperazine (Compazine): Antiemetic used to relieve
symptoms of nausea and vomiting.
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144
MEDS
Common Prescription Abbreviations
and Symbols
Abbreviation
or Symbol Meaning
Abbreviation
or Symbol Meaning
aa of each ml or mL milliliter
ac before meals mm millimeter
AD* right ear NPO nothing by
mouth
AS* left ear OD* right eye
AU* both ears OS* left eye
bid twice a day OU* both eyes
c with pc after meals
cc* cubic centimeters PO by mouth
Caps capsules prn as needed
c/o without Pt patient
g gram qd* every day
gr grain qh* every hour
gt or gtt drop (drops) q (2,3,4)h* every (2,3,4)
hours
hs* at bedtime qid* 4 times a day
IM intramuscular subQ subcutaneous
IU International Units sol solution
IV intravenous Stat at once
kg kilogram Tab tablet

L liter tid 3 times a day
mg milligram ung ointment
*Denotes abbreviation no longer recommended by The Joint Commission.
Instead, spell out the words, such as “every 2 hours” or “every day.”
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145
MEDS
Common Prescription Medications
Generic Name
(DEA Schedule) Brand Name Purpose
albuterol ProAir HFA Bronchodilator
alendronate Fosamax Osteoporosis
allopurinol Zyloprim Antigout
alprazolam (C-IV) Xanax Antianxiety
amitriptyline Elavil Antidepressant
amlodipine Norvasc Calcium channel blocker
amoxicillin Amoxil Antibiotic
arpiprazole Abilify Antidepressant
atenolol Tenormin Beta blocker
atorvastatin Lipitor Cholesterol-lowering
azithromycin Zithromax Antibiotic
benazepril Lotensin ACE inhibitor
budesonide +
formoterol
Symbicort Corticosteroid +
long-acting beta agonist
buprenorphine (C-III) Suboxone Opioid antagonist
carisoprodol (C-IV) Soma Muscle relaxer
carvedilol Coreg Nonselective beta blocker
celecoxib Celebrex NSAID
cephalexin Keﬂ ex Antibiotic
ciproﬂ oxacin Cipro Antibiotic
citalopram Celexa Antidepressant
clonazepam (C-IV) Klonopin Antianxiety
clonidine Catapres Central acting alpha-
agonist hypotensive
clopidogrel Plavix
Antiplatelet
Continued
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146
MEDS
Common Prescription Medications —cont’d
Generic Name
(DEA Schedule) Brand Name Purpose
codeine +
guaifenesin (C-V)
Robitussin
AC Syrup
Antitussive + Expectorant
codeine/APAP (C-III) Tylenol #2 Pain relief
cyclobenzaprine Flexeril Muscle relaxer
dexlansoprazole Dexilant Proton pump inhibitor
diazepam (C-IV) Valium Antianxiety
digoxin Lanoxin Cardiac glycoside
diltiazem Cardizem Vasodilator
donepezil Aricept Acetylcholinesterase
inhibitor
doxycycline Vibramycin Antibiotic
duloxetine Cymbalta Antidepressant
enalapril Vasotec ACE inhibitor
escitalopram Lexapro Antidepressant
esomeprazole Nexium Proton pump inhibitor
estrogen Premarin Estrogen replacement
ezetimibe Zetia Cholesterol-lowering
famotidine Pepcid Histamine 2 blocker
fenoﬁ brate TriCor Cholesterol-lowering
fexofenadine Allegra Antihistamine
ﬂ uconazole Diﬂ ucan Antifungal
ﬂ uoxetine Prozac Antidepressant
ﬂ uticasone Flonase Allergies
folic acid Folvite
Supplement
furosemide Lasix Diuretic
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147
MEDS
Common Prescription Medications —cont’d
Generic Name
(DEA Schedule) Brand Name Purpose
gabapentin Neurontin Antiepileptic
glyburide Diabeta Sulfonylurea
hydrochlorothiazide HCTZ Diuretic
hydrocodone/APAP
(C-III)
Generic only Pain relief
ibuprofen Advil NSAID
insulin Lantus Long-acting basal insulin
latanoprost Xalatan Glaucoma
levoﬂ oxacin Levaquin Antibiotic
levothyroxine Sythroid Thyroid hormone
lisdexamfetamine
(C-II)
Vyvanse Psychostimulant
lisinopril Prinivil ACE inhibitor
lorazepam (C-IV) Ativan Antianxiety
lovastatin Mevacor Cholesterol-lowering
meloxicam Mobic NSAID (Arthritis)
memantine Namenda Alzheimer’s disease
metformin Glucophage Antidiabetic
methylphenidate
(C-II)
Concerta CNS stimulant
methylprednisolone Medrol Corticosteroid
metoprolol Lopressor Beta blocker
mometasone Nasonex Corticosteroid
montelukast Singulair Leukotriene modiﬁ er
naproxen Aleve NSAID
Continued
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148
MEDS
Common Prescription Medications —cont’d
Generic Name
(DEA Schedule) Brand Name Purpose
niacin Niaspan Cholesterol-lowering
olanzapine Zyprexa Antipsychotic
olmesartan Benicar Angiotensin receptor
blocker
omeprazole Prilosec Inhibits gastric acid
secretion
oxycodone (C-II) OxyContin Pain relief
oxycodone/APAP
(C-II)
Percocet Pain relief
pantoprazole Protonix Proton pump inhibitor
paroxetine Paxil Antidepressant
penicillin Pen VK Antibiotic
pioglitazone Actos Antihyperglycemic
potassium K-Tab Electrolyte
pravastatin Pravachol Cholesterol-lowering
prednisone Deltasone Anti-inﬂ ammatory
pregabalin Lyrica Anticonvulsant
promethazine Phenergan Antihistamine
quetiapine Seroquel Antipsychotic
ranitidine Zantac Histamine 2 blocker
risedronate Actonel Bone resorption inhibitor
rosuvastatin Crestor Cholesterol-lowering
sertraline Zoloft Antidepressant
simvastatin Zocor Cholesterol-lowering
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149
MEDS
Common Prescription Medications —cont’d
Generic Name
(DEA Schedule) Brand Name Purpose
sitaglibtin Januvia Dipeptidyl peptidase
inhibitor
tamsulosin Flomax Adrenergic receptor
antagonist
tiotropium Spiriva Bronchodilator
tolterodine Detrol Muscarinic receptor
antagonist
tramadol Ultram Pain relief
trazodone Desyrel Antidepressant
triamterene/HCTZ Dyazide Diuretic combo
valsartan Diovan Angiotensin receptor
blocker and diuretic
venlafaxine Effexor Antidepressant
warfarin Coumadin Blood thinner
zolpidem (C-IV) Ambien Sleep aid
Data from http://www.pharmacy-tech-test.com/top-200-drugs.html
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150
MEDS
Notes

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151
MEDS
Notes

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152
Guidelines for Surgical Asepsis
■ A 1-inch border around the sterile ﬁ eld is considered
contaminated.
■ Hold sterile items above the waist. Items held below the
waist are considered contaminated.
■ Always face the sterile ﬁ eld, and never reach over the ﬁ eld.
■ Place items in the center of the ﬁ eld.
■ If you must leave the ﬁ eld, place a sterile towel over the
ﬁ eld.
■ Never cough or sneeze over the sterile ﬁ eld.
■ Try not to spill anything on the sterile ﬁ eld.
■ If a sterile object comes in contact with an unsterile item, it
is considered contaminated and cannot be used.
■ If in doubt about the sterility of an item, DO NOT USE it.
■ If the sterile ﬁ eld has been broken, start setup again from
the beginning.
Asepsis Processes
Process Type Items
Sanitization
Removes visible
contamination or
organic material from
article
Manual and
ultrasonic
Scissors, forceps,
needle holders
Disinfection
Destroys pathogenic
microorganisms but
not necessarily their
spores
Chemical
(alcohol,
glutaraldehyde,
quaternary
ammonium
compounds)
Specula, ﬂ exible
ﬁ beroptic
sigmoidoscopes,
stethoscopes,
surfaces
Sterilization
Completely destroys
microorganisms and
their spores
Chemical,
autoclave,
radiation, dry
heat oven, gas
Medical and surgical
instruments, liquids,
powders, brushes,
dressings, glassware
OFFICE
SURGERY
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153
OFFICE
SURGERY
Autoclave Procedure
1. After sanitizing or disinfecting articles to be autoclaved,
wrap according to ofﬁ ce protocol. Label wrapped items with
contents, date, and initials.
2. Fill autoclave water chamber with distilled water according
to manufacturer’s instructions.
3. Load autoclave appropriately.
4. Close and lock autoclave door.
5. Set proper temperature and time. Remember to time load
after proper temperature has been reached and according to
manufacturer’s instructions.
Instruments
Functions
Function Instruments
Cutting Scissors, scalpel
Grasping or
clamping
Hemostat, forceps, clamp, needle holder
Probing or dilating Speculum, scope, probe, retractor, dilator
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154
OFFICE
SURGERY
Grasping or Clamping Instruments

Backhaus Towel Clamp. (From Rutherford, CJ. Differentiating
Surgical Instruments , 2nd edition. Philadelphia: F.A. Davis,
2011, p. 1.)

Foerster Sprong Clamps. (From Rutherford, CJ. Differentiating
Surgical Instruments , 2nd edition. Philadelphia: F.A. Davis,
2011, p. 2.)

Crile-Wood Needle Holder. (From Rutherford, CJ.
Differentiating Surgical Instruments , 2nd edition. Philadelphia:
F.A. Davis, 2011, p. 3.)
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155
OFFICE
SURGERY

Mayo-Heger Needle Holder. (From Rutherford, CJ.
Differentiating Surgical Instruments , 2nd edition. Philadelphia:
F.A. Davis, 2011, p. 3.)

Webster Needle Holder. (From Rutherford, CJ. Differentiating
Surgical Instruments , 2nd edition. Philadelphia: F.A. Davis,
2011, p. 4.)

Crile Hemostatic Clamp. (From Rutherford, CJ. Differentiating
Surgical Instruments , 2nd edition. Philadelphia: F.A. Davis,
2011, p. 11.)
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156
OFFICE
SURGERY
Probing or Dilating Instruments

Guthrie Retractor (Guthrie double skin hook). (From Rutherford,
CJ. Differentiating Surgical Instruments , 2nd edition.
Philadelphia: F.A. Davis, 2011, p. 19.)

Graves Vaginal Speculum. (From Rutherford, CJ. Differentiating
Surgical Instruments , 2nd edition. Philadelphia: F.A. Davis,
2011, p. 41.)

Cottle Nasal Speculum. (From Rutherford, CJ. Differentiating
Surgical Instruments , 2nd edition. Philadelphia: F.A. Davis,
2011, p. 112.)
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157
OFFICE
SURGERY

Hank Dilator. (From Rutherford, CJ. Differentiating Surgical
Instruments , 2nd edition. Philadelphia: F.A. Davis, 2011, p. 41.)

Arthroscope. (From Rutherford, CJ. Differentiating Surgical
Instruments , 2nd edition. Philadelphia: F.A. Davis, 2011, p. 78.)

Arthroscopic Probe. (From Rutherford, CJ. Differentiating
Surgical Instruments , 2nd edition. Philadelphia: F.A. Davis,
2011, p. 78.)
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158
OFFICE
SURGERY
Sutures
Suture: verb —to sew a wound, bring edges together (approxi-
mate); noun —material used to sew a wound.
Common Suture Materials

■ Black silk
■ Catgut
■ Chromic catgut
■ Dacron
■ Dermalon
■ Ethilon
■ Mersilene
■ Nylon
■ Prolene
■ Silk
■ Tevdek
■ Vicryl
Suture Sizing
Largest to smallest
■ 4
■ 3
■ 2
■ 1
■ 0
■ 2–0
■ 3–0
■ 4–0
■ 5–0
■ 6–0
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159
OFFICE
SURGERY
Common Ofﬁ ce Surgical Procedures
Suturing a Laceration
Setup
Equipment and Supplies
Surgical Tray Side Area
Syringe/needle for anesthesia Anesthesia, as ordered
Hemostats (curved) Dressing
Adson or tissue forceps Bandages
Iris scissors (curved) Tape
Suture material and needle Splint, brace, sling, as needed
Needle holder Sterile gloves
Gauze sponges
Procedure
Before and during the procedure:
■ Wash your hands.
■ Identify the patient.
■ Explain the procedure.
■ Check for signed consent and patient understanding.
■ Determine allergies, tetanus booster, and health concerns.
■ Soak the wound in antiseptic solution, as ordered.
■ Clean and dry the wound.
■ Position the patient lying down as comfortable as possible.
■ Assist the physician as needed.
■ Support and comfort the patient.
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160
OFFICE
SURGERY
After the procedure:
■ Apply sterile gloves.
■ Clean the area around the wound.
■ Dress and bandage the wound as directed.
■ Dispose of all items per OSHA guidelines.
■ Remove gloves, and wash your hands.
■ Check the patient’s vital signs.
■ Explain wound care to the patient or caregiver.
■ Provide written postoperative instructions.
■ Answer questions.
■ Make a follow-up appointment as necessary.
■ Document the procedure.
Suture Removal
Equipment and Supplies
■ Gauze sponges
■ Bandage scissors
■ Biohazard waste container
■ Tape
■ Sponge forceps
■ Suture removal kit, including:
■ Suture scissors or staple remover
■ Thumb forceps
■ 4 ″ × 4 ″ gauze pads
■ Sterile latex gloves
■ Betadine solution or wash
Procedure
■ Gather supplies.
■ Identify the patient.
■ Wash your hands.
■ Open the suture removal kit.
■ Apply sterile gloves.
■ Using thumb forceps, gently pick up one knot of a suture.
■ Gently pull upward toward the suture line.
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161
OFFICE
SURGERY
■ Using suture removal scissors, cut one side of the suture as
close to the skin as possible.
■ Pull the suture through the skin.
■ Avoid contaminating the wound.
■ Remove all sutures in the same manner.
■ Place each suture on the sterile gauze sponge.
■ Examine wound to ensure that all sutures have been
removed.
■ Apply Betadine solution to the area.
■ Apply sterile dressing if directed.
■ Remove gloves.
■ Dispose of used items per OSHA regulations.
■ Wash your hands.
■ Explain wound care and give written instruction to the
patient.
■ Make a follow-up appointment as directed.
■ Document the procedure.

Setup for Suturing a Laceration
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OFFICE
SURGERY
Incision and Drainage of a Localized Infection
Equipment and Supplies
Surgical Tray Side Area
Syringe and needle for
anesthesia
Skin prep supplies
Scalpel blades and handle Gloves—sterile and nonsterile
Thumb forceps PPE
Gauze sponges Anesthesia (as directed)
Fenestrated drape Dressing, bandages, tape
Tissue forceps Specimen container (if
directed)
Mayo scissors Biohazard waste container
Iris scissors Gauze sponges
Betadine in sterile cup Iodoform gauze wick or
Penrose drain
Alcohol pledget
Antiseptic solution
Culturette (if directed)
Procedure
Before and during the procedure:
■ Identify the patient, wash your hands, and explain the
procedure.
■ Check tetanus booster and allergy history.
■ Check for signed consent, patient understanding, and health
concerns.
■ Position the patient and put on PPE and nonsterile gloves.
■ Apply antiseptic soap with a 4 ″ × 4 ″ gauze pad in an outward
circular motion.
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OFFICE
SURGERY
■ Using a razor and holding the skin taut, shave the operative
area following the hair growth pattern.
■ Scrub the shaved area with antiseptic soap in an outward
circular motion for 2 to 5 minutes.
■ Rinse the shaved area with sterile water and dry with a
sterile 4 ″ × 4 ″ gauze sponge.
■ Wash your hands.
■ Using sterile transfer forceps, remove the sterile towel and
place it under the operative site.
■ Cover the operative site with the sterile towel, instructing
the patient not to touch the site.
■ Pour Betadine into a sterile bowl.
■ Using sterile technique, paint the operative site with
Betadine.
■ Let the site dry, and drape the patient with sterile drapes.
■ Assist the physician as directed with anesthesia
administration.
■ The physician will incise the abscess and insert Iodoform
gauze or a Penrose drain into the wound.
■ Provide support and comfort the patient as needed.
After the procedure:
■ Apply sterile gloves.
■ Clean the area around the wound.
■ Dress and bandage the wound as directed.
■ Dispose of all items per OSHA guidelines.
■ Remove gloves and wash your hands.
■ Check the patient’s vital signs.
■ Explain wound care to the patient or caregiver.
■ Provide written postoperative instructions.
■ Answer questions and make a follow-up appointment as
necessary.
■ Document the procedure.
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OFFICE
SURGERY
Notes

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Key Externship Information
Name of Practice: ___________________________________________
   Physician(s):
_____________________________________________________________
   _____________________________________________________________
   Address: ____________________________________________________
   Ofﬁ ce Number (main): _______________________________________
   Ofﬁ ce Number (private): _____________________________________
   Ofﬁ ce Manager: _____________________________________________
   Ofﬁ ce Staff
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
   Hours of Operation: _________________________________________
   Special Considerations
_____________________________________________________________
_____________________________________________________________
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Externship Schedule
Month 1
SUN     MON     TUES     WED     THUR     FRI     SAT






Month 2
SUN     MON     TUES     WED     THUR     FRI     SAT






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TOOLS
English-to-Spanish Translations
Conversational and Administrative
Good morning Buenos días
Good afternoon Buenos tardes
What is your name? ¿Cómo se llama?
Does he/she speak English? ¿El/ella habla inglés?
What is your home address? ¿Cual es su dirección?
What is your telephone number? ¿Cual es su número de
teléfono?
Do you have an insurance card? ¿Tiene usted su tarjeta
de insurance?
Appointment
Days
Monday   Lunes
Tuesday   Martes
Wednesday   Miércoles
Thursday   Jueves
Friday   Viernes
Saturday   Sábado
Sunday   Domingo
Months
January   Enero
February   Febrero
March   Marzo
April   Abril
May   Mayo
June   Junio
July   Julio
August   Agosto
September   Septiembre
October   Octubre
November   Noviembre
December   Diciembre
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TOOLS
Numbers
one   uno
two   dos
three   tres
four   cuatro
ﬁ ve cinco
six   seis
seven   siete
eight   ocho
nine   nueve
ten   diez
eleven   once
twelve   doce
Time
It’s 1:00. Es la una. (Use “es” only with “una.”)
It’s 2:00. Son las dos.
It’s 3:00. Son las tres.
It’s 1:15. Es la una y cuarto./Es la una y quince.
It’s 2:15. Son las dos y cuarto./Son las dos y quince.
It’s 1:30. Es la una y media.
It’s 2:30. Son las dos y media.
It’s 1:45. Son las dos menos cuarto./Son las dos menos
quince.
It’s 2:45. Son las tres menos cuarto./Son las tres menos
quince.
at 1:00 a la una
at 2:00 a las dos
at 3:00 a las tres
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Clinical
How do you feel? ¿Cómo se sienta?
How are you? ¿Cómo está usted?
Good/well   Bien
Bad   Mal
Tired   Cansado/cansada, sueño
Weak   Débil
Dizzy   Mareos
Are you thirsty? ¿Tiene sed?
Are you nauseous? ¿Siente usted náuseas?
Do you take any
medications?
¿Toma usted alguna medicina?
May I take your blood
pressure?
¿Podría tomar su presion
arterial?
May I take your temperature? ¿Podría tomar su temperatura?
Please give me a urine
sample.
Deme una muestra de orina,
por favor.
Are you allergic to any
drugs?
¿Es alergico a ciertas drogas?
May I help you? ¿Puedo ayudarlo?
Fever   Fiebre
I am going to ask you
questions.
Voy a hacerle preguntas.
Health insurance Seguro de salud
Excuse me Con permiso
Can you breathe? ¿Puede respirar?
Are you cold? ¿Tiene frió?
Are you hot? ¿Tiene calor?
Do you have help at home? ¿Tiene ayuda en casa?
Will you need help? ¿Va a necesitar ayuda?
Do you have medical
problems?
¿Tiene problemas medicas?
Do you have cardiac
problems?
¿Tiene problemas cardíacos?
Do you have respiratory
problems?
¿Tiene problemas
respiratorios?
Do you have renal problems?
¿Tiene problemas renales?
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Commands
Breathe in. Respire.
Breathe out. Saque el aire.
Hold your breath. Sostenga la respiración.
Open your mouth. Abra la boca.
Open your eyes. Abra los gós.
Follow my ﬁ nger. Siga mi dedo.
Relax your leg. Relaje la pierna.
Relax your arm. Relaje el brazo.
Squeeze my hand. Apriete mi mano.
Stick your tongue out. Saque la lengua.
Tell me if this hurts. Digame si esto le duele.
Please ﬁ ll out these papers. Por favor llene estos papeles.
Tell me why you are here. Digame por qué esta aqui.
Pain
How severe is the pain? ¿Que tan severo es dolor?
On a scale of 1 to 10? ¿En una escala del uno al diez?
Have you ever had a heart
attack?
¿Ha tenido alguna vez un
ataque cardiaco?
How old are you? ¿Cuántos años tiene?
Is there numbness/a tingling
sensation/burning in your
leg/arm/foot/hand?
¿Esta entumecido/adormecido/
tiene andoz ensu pierna/
brazo/pie/mano?
Do you have allergies? ¿Tiene alergias?
To foods? a comidas?
To drugs? a medicamentos?
To plants? a plantas?
Does the pain move from one
place to another?
¿El dolor se mueve de unlugar
a otro?
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Patient Questions
Do you smoke? ¿Fuma usted?
Do you drink alcohol? ¿Toma bebidas alcohólicas?
Do you use drugs? ¿Usa drogas?
Do you engage in protective
sex?
¿Practica el sexo seguro?
Have you had surgeries? ¿Qué clase de operaciones?
Do you live by yourself? ¿Vive solo?
Can you...? ¿Puedo usted...?
Do you have...? ¿Tiene...?
Have you had...? ¿Ha tenido...?
What is your date of birth? ¿Fecha de nacimiento?
I will start by taking vital
signs.
Voy a empezar por tomar los
signos vitals.
Do you understand? ¿Entiende?
Where does it hurt? ¿Donde le duele?
Point Apunte
Did you fall? ¿Se cayó?
Did you lose consciousness? ¿Perdio el conocimiento?
Did you faint? ¿Se desmayó?
Do you feel nauseated? ¿Siente náuseas?
Do you feel weak? ¿Se siente débil?
Do you feel dizzy? ¿Se siente mareado?
They will talk to your family. Le dejarán hablar con su
familia.
What do you do? ¿Qué hace usted?
Are you employed? ¿Trabaja usted?
Try to calm down. Trate de calmarse.
Did you take medication
today?
¿Tomó sus medicinas hoy?
When? ¿Cuando?
What were you doing? ¿Qué estaba hacienda?
Has pain gotten worse or
better?
¿Se ha puesto el dolor peor o
major?
Did you take drugs or alcohol
in the last 3 hours?
¿Tomo drogas o alcohol en
las últimas tres horas?
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Common Medical Abbreviations
Abbreviation Meaning
   ABG arterial blood gas
   a.c. before a meal
   ACE angiotension converting enzyme
   ACTH adrenocorticotropic hormone
   a.d.* right ear (auris dextra)
   ADH antidiuretic hormone
   ADHD attention-deﬁ cit hyperactivity disorder
   AF atrial ﬁ brillation
   AFP alpha-fetoprotein
   A/G, A-G ratio albumin/globulin ratio
   Ag silver; antigen
   AgNO
3 silver nitrate
   AIDS acquired immune deﬁ ciency syndrome
   Al aluminum
   Alb albumin
   ALS amyotrophic lateral sclerosis
   ALT alanine aminotransferase
   a.m.a., AMA against medical advice
   amp ampule; amputation
   ANA antinuclear antibody
   AP anteroposterior
   A & P auscultation and percussion
   ARC AIDS-related complex
   ARMD age-related macular degeneration
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TOOLS
Abbreviation Meaning
   a.s. left ear (auris sinistra)
   AS ankylosing spondylitis
   AST aspartate aminotransferase
   Ba barium
   BBB blood-brain barrier
   BE barium enema
   b.i.d. twice a day
   BM bowel movement
   BMR basal metabolic rate
   BP blood pressure
   BPH benign prostatic hypertrophy
   bpm beats per minute
   Bx biopsy
   CAD coronary artery disease
   C&S culture and sensitivity
   CBC complete blood count
   CC chief complaint
   cc* cubic centimeter
   CDC Centers for Disease Control and Prevention

CF cystic ﬁ brosis
   CHF congestive heart failure
   CIS carcinoma in situ
   CK creatine kinase
   cm centimeter
   CMV cytomegalovirus
   CNS central nervous system
Continued
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Abbreviation Meaning
   CO
2 carbon dioxide
   COLD chronic obstructive lung disease
   COPD chronic obstructive pulmonary disease
   CP cerebral palsy
   CPR cardiopulmonary resuscitation
   CSF cerebrospinal ﬂ uid
   CV cardiovascular
   CVA cerebrovascular accident; also called  stroke
   D&C dilatation and curettage
   DC doctor of chiropractic
   DJD degenerative joint disease
   DM diabetes mellitus
   DNR do not resuscitate
   DPT diphtheria-pertussis-tetanus (vaccine)
   DRG diagnosis-related group
   DTR deep tendon reﬂ ex
   Dx diagnosis
   ECG electrocardiogram
   EEG electroencephalogram
   ELISA
enzyme-linked immunosorbent assay
   EMG electromyogram
   ENT ear, nose, and throat
   ESR erythrocyte sedimentation rate
   Fe iron
   FEV forced expiratory volume
   FSH follicle-stimulating hormone
   FUO fever of unknown origin
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Abbreviation Meaning
   g, gm gram
   GERD gastroesophageal reﬂ ux disease
   GH growth hormone
   GI gastrointestinal
   GSW gunshot wound
   GTT glucose tolerance test
   GU genitourinary
   GYN gynecology
   HCG human chorionic gonadotropin
   HCT hematocrit
   HDL high-density lipoprotein
   HEENT head, eyes, ears, nose, and throat
   HF heart failure; formerly called  congestive
heart failure (CHF)
   Hg mercury
   Hgb hemoglobin
   HIV human immunodeﬁ ciency virus
   HPI history of present illness
   HR heart rate

HSR herpes simplex virus
   HTN hypertension
   Hx history
   I&O intake and output
   ICU intensive care unit
   IDDM insulin-dependent diabetes mellitus
   IM intramuscular
Continued
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Abbreviation Meaning
   IPPB intermittent positive-pressure breathing
   IQ intelligence quotient
   IV intravenous
   IVP intravenous pyelogram
   K potassium
   KUB kidneys, ureters, bladder
   L liter
   L&D labor and delivery
   LDL low-density lipoprotein
   lmp last menstrual period
   LLE left lower extremity
   LOC loss of consciousness
   LP lumbar puncture
   LUE left upper extremity
   LV left ventricle
   MA mental age
   mcg microgram
   MCH mean corpuscular hemoglobin
   MCHC mean corpuscular hemoglobin
concentration
   MCV mean corpuscular volume
   MD muscular dystrophy
   mEq milliequivalent
   Mg magnesium
   mg milligram
   MI myocardial infarction
   mL milliliter
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TOOLS
Abbreviation Meaning
   mm millimeter
   MRI magnetic resonance imaging
   MS mitral stenosis; multiple sclerosis
   MVA motor vehicle accident
   Na sodium
   NG nasogastric
   NICU neonatal intensive care unit
   NIDDM non–insulin-dependent diabetes mellitus
   NKA no known allergies
   NMR nuclear magnetic resonance
   NSAID nonsteroidal anti-inﬂ ammatory drug
   OB obstetrics
   O.D.* right eye (oculus dexter)
   ORIF open reduction, internal ﬁ xation
   OTC over the counter
   OU* each eye (oculus uterque)
   Pap test Papanicolaou test
   Pb lead
   PCP
primary care physician
   PE physical examination
   PERRLA pupils equal, round, and reactive to light
and accommodation
   PET positron emission tomography
   pH hydrogen ion concentration
   PI present illness
   PID pelvic inﬂ ammatory disease
Continued
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TOOLS
Abbreviation Meaning
   PKU phenylketonuria
   PMH past medical history
   p.o. orally (per os)
   PSA prostate-speciﬁ c antigen
   PT prothrombin time
   PTT partial thromboplastin time
   PVC premature ventricular contraction
   QNS quantity not sufﬁ cient
   RA rheumatoid arthritis
   RBC red blood cell
   RDA recommended daily allowance
   RDS respiratory distress syndrome
   REM rapid eye movement
   RLE right lower extremity
   R/O rule out
   ROM range of motion
   ROS review of systems
   RUE right upper extremity
   SA
sinoatrial
   sed rate sedimentation rate
   SIDS sudden infant death syndrome
   SLE systemic lupus erythematosus
   SOB shortness of breath
   STD sexually transmitted disease
   TB tuberculin; tuberculosis
   TENS transcutaneous electrical nerve stimulation
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TOOLS
Abbreviation Meaning
   TIA transient ischemic attack
   TM tympanic membrane
   TMJ temporomandibular joint
   TPN total parenteral nutrition
   TPR temperature, pulse, respiration
   TSH thyroid-stimulating hormone
   TURP transurethral resection of the prostate
   UA urinalysis
   UE upper extremity
   UI urinary tract infection
   URI upper respiratory infection
   VA visual acuity
   VD venereal disease
   VLDL very low-density lipoprotein
   WBC white blood cell
   WDWN well-developed, well-nourished
   WF/BF white female, black female
   WM/BM white male, black male
   WNL within normal limits

Zn zinc
* The Joint Commission recommends discontinuance of these abbreviations. For
the most current listing of discontinued abbreviations, refer to The Joint
Commission’s Website.
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TOOLS
Medical Terminology
Word Element Meaning
   a-, an- without, not; away from
   ab-, abs- from, away from; absent
   abdomin/o abdomen
   acous-, acoust/o hearing
   acro- extremity; top
   ad- adherence; increase; toward
   -ad toward, in the direction of
   aden/o gland
   adip/o fat
   adren/o, adrenal/o adrenal glands
   aer/o air
   -al relating to
   -algesia, -algia, algi- suffering, pain
   allo-, all- other
   amb-, ambi- both, on both sides; around, about
   amph-, amphi-, ampho- both, on both sides; on all sides;
double
   andro- male
   angi/o blood or lymph vessel
   ankyl/o crooked, bent; fusion (growing
together of parts)
   ante- before
   ant-, anti- against
   arteri/o artery
   arthr/o joint
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TOOLS
Word Element Meaning
   -ase enzyme
   -asis, -esis, -iasis, -isis,
-osis
condition; pathological state
   astr/o star-shaped
   ather/o fatty plaque
   aut-, auto- self
   balan/o glans clitoris; glans penis
   bi-, bis- two
   blast-, -blast germ; bud; embryonic state of
development
   blephar/o eyelid
   brachio arm
   brady- slow
   bronchi/o airway
   bronchiol/o bronchiole
   carcin/o cancer
   caut/o burn
   -cele tumor; swelling; hernia
   cephal/o head
   cervic/o neck, the neck of an organ
   cheil/o
lip
   chol-, chole- bile; gall
   cholangi/o bile vessel
   cholecyst/o gallbladder
   choledoch/o bile duct
   chondr/o cartilage
Continued
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TOOLS
Word Element Meaning
   cleid/o clavicle
   col/o colon
   contra- against
   crani/o skull
   cry/o cold
   cyan/o blue
   cyst/o, -cyst cyst, urinary bladder
   cyt/o, -cyte cell
   dactyl/o ﬁ nger; toe
   dent/o teeth
   derma, dermat/o skin
   dipla-, diplo- double, twin
   dors/o back
   -dynia pain
   dys- difﬁ cult; bad; painful
   ect/o out; on the outside
   -ectomy excision
   -emesis vomiting
   -emia
blood
   en- in, into
   end/o within
   enter/o intestine
   ep-, epi- upon; over; at; in addition to; after
   erythr/o red
   esophag/o esophagus
   -esthesia sensation
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TOOLS
Word Element Meaning
   ex- out; away from; completely
   exo- out; outside of; without
   ﬁ br/o ﬁ bers; ﬁ brous tissue
   galact/o milk
   gastr/o stomach
   gen-, -gen, -gene, -genesis   producing; forming
   genito- organs of reproduction
   gingiv/o gums (of the mouth)
   glosso- tongue
   gluc/o, glyc/o sugar
   -gram tracing; mark
   -graph instrument used to make a
drawing or record
   gyn-, gynec/o woman; female
   hem/o, hemat/o blood
   hemi- half
   hepat/o liver
   hist/o tissue
   hydr/o water

hypo- under; below
   hyper- above; excessive; beyond
   hypno- sleep
   hyster/o uterus
   ile/o ileum
   ili/o ilium; ﬂ ank
   infra- below, under, beneath, inferior
Continued
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TOOLS
Word Element Meaning
   inter- between; in the midst
   intra, intro- within; in; into
   -itis inﬂ ammation
   kary/o nucleus
   kera-, kerat/o horny substance; cornea
   kinesi-, -kinesis movement
   laryng/o larynx
   later/o side
   leio- smooth
   leuk/o white
   lingu/o tongue
   lip-, lipo- fat
   lith-, litho- stone; calculus
   -oma tumor
   onych/o ﬁ ngernails; toenails
   oo-, ovi-, ovo- egg; ovum
   oophor/o ovary
   ophthalm/o eye
   -opia
vision
   orchid/o testicle
   oro- mouth
   orth/o straight; correct; normal
   oste/o bone
   -ostomosis, -ostomy created mouth or outlet
   oto- ear
   -otomy cutting
   -pachy thick
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TOOLS
Word Element Meaning
   pan- all
   para- near; alongside of; departure from
normal
   -para bearing offspring
   path/o disease; suffering
   ped-, ped/i, pedo- foot
   pedi- child
   -penia decrease from the normal,
deﬁ ciency
   peri- around; about
   -pexy ﬁ xation (usually surgical)
   phag/o to eat
   phalang/o phalanges (bones of the ﬁ ngers
and toes)
   -phil, -philia love for; tendency towards;
craving for
   phlebo- vein
   -phobia abnormal fear or aversion
   phono- sound; voice
   -phoresis transmission
   phren/o mind
   -plasia
growth; cellular proliferation
   -plegia paralysis; stroke
   pneum/o air; lung
   pod/o foot
   -poiesis, -poietic production; formation
   poly- many
Continued
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TOOLS
Word Element Meaning
   post- after
   postero- posterior; behind; toward the back
   pre- before; in front of
   proct/o anus; rectum
   prostat/o prostate gland
   pseud/o false
   psych/o mind; mental processes
   pulmo- lung
   py-, pyo- pus
   pyelo- pelvis
   pyreto- fever
   recto- straight; rectum
   ren/o kidney
   retro- backward; back; behind
   rheo-, -rrhea to discharge; current, stream, ﬂ ow
   rhino- nose
   -rrhage, -rrhagia rupture; profuse ﬂ uid discharge
   -rraphy suturing or stitching
   -rrhexis
rupture (of a speciﬁ c body part)
   sacchar/o sugar
   salping/o fallopian tube
   sarc/o ﬂ esh
   scapulo- shoulder
   schizo- split; cleft
   sclero- hard; related to the sclera
   -sclerosis dryness; hardness
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187
TOOLS
Word Element Meaning
   -scope instrument for viewing or
examining
   -scopy examination
   semi- half
   sial-, sialo- saliva
   somat/o body
   spleno- spleen
   spondyl/o vertebra
   staphyl/o grapelike cluster
   steato- fat
   sterno- sternum
   steth/o chest
   stomat/o mouth
   strepto- twisted
   sub- under; beneath; in small quantity
   super- above; beyond; superior
   supra- above; beyond; on top
   sym- with, together with; along, beside
   syn- joined, together
   tachy- swift, rapid
tarso- ﬂ at of the foot; edge of the eyelid
   tendo-, teno- tendon
   terato- severely malformed fetus
   thermo- heat
   thorac/o chest
   thrombo- clot
Continued
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188
TOOLS
Word Element Meaning
   thy-, thyro- thyroid
   -tome cutting instrument
   -tomy cutting procedure; excision
   top-, topo- place
   toxic/o toxin, poison
   trache/o trachea
   trans- across; over; beyond; through
   trich/o hair
   troph/o nourishment
   -tropin stimulation of a target organ
   tympan/o tympanum (eardrum)
   ultra- beyond; excessive
   uretero- ureter
   urethro- urethra
   -uria urine
   uter/o uterus
   vagin/o vagina
   vaso- vessel
   veno- vein

ventr/o abdomen
   vertebro- vertebra
   vesico- bladder; vesicle
   viscero- viscera
   xero- dry
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189
TOOLS
Schedule Planner/Organizer Month________
     RN      CPR      CMA
    LPN      ACLS      Other
    Sunday     Monday     Tuesday     Wednesday     Thursday     Friday     Saturday






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190
TOOLS
Schedule Planner/Organizer Month________
     RN      CPR      CMA
    LPN      ACLS      Other
    Sunday     Monday     Tuesday     Wednesday     Thursday     Friday     Saturday






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191
TOOLS
Schedule Planner/Organizer Month________
RN    CPR    CMA
   LPN    ACLS    Other
   Sunday     Monday     Tuesday     Wednesday     Thursday     Friday     Saturday






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192
TOOLS
Useful Internet Websites
■ Academy of Nutrition and Dietetics—www.eatright.org
   ■ American Academy of Pediatrics—www.aap.org
   ■ American Association of Medical Assistants—www.aama-ntl.
org
   ■ American Cancer Society—www.cancer.org
   ■ American Diabetes Association—www.diabetes.org
   ■ American Heart Association—www.heart.org
   ■ American Lung Association—www.lungusa.org
   ■ American Red Cross—www.redcross.org
   ■ American Society for Clinical Pathology—www.ascp.org
   ■ Becton, Dickinson, and Company—www.bd.com
   ■ Centers for Disease Control and Prevention—www.cdc.gov
   ■ U.S. Drug Enforcement Administration—www.dea.gov
   ■ U.S. Food and Drug Administration—www.fda.gov
   ■ MSDS Solutions Center—www.msds.com
   ■ Medicaid—www.medicaid.gov
   ■ Medicare—www.medicare.gov
   ■ Medical dictionary at MedicineNet—www.medterms.com
   ■ Medical Transcription (MT) Desk—www.mtdesk.com
   ■ National Institutes of Health—www.nih.gov
   ■ Occupational Safety and Health Administration (OSHA)—
www.osha.gov
   ■ RxList: The Internet Drug Index—www.rxlist.com
   ■ The National Women’s Health Information Center—www.
healthywomen.org
   ■ U.S. Department of Health and Human Services—www.hhs.
gov
   ■ U.S. Government health information—www.healthﬁ nder.gov
   ■ World Health Organization—www.who.int/en
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193
TOOLS
Notes
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194
TOOLS
Notes
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195
INDEX
A
Abbreviations, medical, 172–179
Abdomen, 106
Abilify (arpiprazole), 145
Abuse, reporting, 7
ACE inhibitors, 140
Acetaminophen, 142
Actonel (risedronate), 148
Actos (pioglitazone), 148
Adrenalin, 143
Advil (ibuprofen), 147
Airway, 116
Albuterol, 143, 145
Alendronate, 145
Aleve (naproxen), 147
Allegra (fexofenadine), 146
Allergy testing, procedure
codes for, 40
Allopurinol, 145
Alphabetical ﬁ ling systems,
14–15
Alprazolam (C-IV), 145
Alternative/holistic medicine,
procedure codes for, 41
Ambien (zolpidem) (C-IV), 149
Aminophylline, 143
Amitriptyline, 145
Amlodipine, 145
Amoxicillin, 141, 145
Amoxil (amoxicillin), 141, 145
Ampicillin, 141
Analyzers, 126
Anatomical charts, 105–115
Antianxiety drugs, 140
Antibiotics, 140
Antidiabetics, 140
Antihyperlipidemics, 140
Antiviral drugs, 140
Apothecary measures, 134
Apps, nutrition, 104
Aricept (donepezil), 146
Arpiprazole, 145
Arthroscope, 157
Arthroscopic probe, 157
Artifacts, 88–89
Aspirin, 141
Atenolol, 145
Ativan (lorazepam) (C-IV), 147
Atorvastatin, 145
Authorization, 8
Autoclave procedure, 153
Availability, 2

Azithromycin, 145
B
BAC (business associate
contract), 8
Backhaus Towel Clamp, 154
Bacterial infection, stool
collection for, 130
Banking, 24
Benadryl (diphenhydramine),
143
Benazepril, 145
Benicar (olmesartan), 148
Beta blockers, 140
Billing, 27–51
health insurance terms, 35
International Classiﬁ cation of
Diseases (ICD), 43–51
procedural terms, 36–37
procedure codes, 38–42
request for payment,
processing, 27–34
Index
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196
INDEX
Biohazards, 56–57
Birthday rule, 35
Blood, donating, 117
Blood chemistry, general,
127–128
Blood pressure (BP), 61, 63
BMI (body mass index), 100
Body planes, 105
Bone marrow, donating, 117
Breathing, 116
Budesonide + formoterol, 145
Buprenorphine (C-111), 145
Business associate, 1
Business associate contract
(BAC), 8
C
CAB (circulation, airway,
breathing), 115–116
Caffeine, 141
Calcium channel blockers, 140
Candida , 75–76
KOH preparation for, 75
Cardiac cycle, 88
Cardizem (diltiazem), 146
Carisoprodol (C-IV), 145
Carvediolol, 145
Catapres (clonidine), 145
Celebrex (celecoxib), 145
Celecoxib, 145
Celexa (citalopram), 145
Cephalexin, 145
Charting guidelines, 64–65
Chlorothiazide, 143
Chlorothiazide (Diuril), 143
Cipro (ciproﬂ oxacin), 145
Ciproﬂ oxacin, 145
Citalopram, 145
Clamping or grasping
instruments, 153–155
Clean claim, deﬁ nition of, 35
CLIA-waived test kits and
analyzers, 125–126
Clonazepam (C-IV), 145
Clonidine, 145
Clopidogrel, 145
CMS-1500 (02-12) Form, 28–33
Codeine + guaifenesin (C-V),
146
Coding, 36–42. See also Current
Procedural Terminology
Colonoscopy, patient prep for,
82
Color vision, Ishihara test for,
84
Communicable diseases
disclosure, 7
Communication skills, 18–23
e-mail, 22
fax, 22–23
ﬁ ve Cs of communication, 18
forms of communication,
18–20
letter, parts of, 19
misspelled words, 20
telephone, 20–22
written, 18–20
Compazine (prochlorperazine),
143
Compliance plan, 11
Compressions, 116
Concerta (methylphenidate)
(C-II), 147
Conﬁ dentiality, 2
Consent for use or disclosure
for TPO, 8
Containers, 56
Controlled substances, 142
Conversion tables, 134
Copay, deﬁ nition of, 35
Coreg (carvediolol), 145
Cottle Nasal Speculum, 156
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197
INDEX
Coumadin (warfarin), 141–142,
149
Court orders, 7
CPR/ﬁ rst aid, teaching, 115–116
Crestor (rosuvastatin), 148
Crile Hemostatic Clamp, 155
Crile-Wood Needle Holder, 154
Current Procedural Terminology
(CPT), 36–42
common procedure codes,
38–42.
modiﬁ ers, 36–37
sections, 36
CVMS, 130
Cyclobenzaprine, 146
Cyclosporine, 141
Cymbalta (Duloxetine), 146
D
Data use agreement, 8
Deceased persons, 7
Deductible, deﬁ nition of, 35
De-identiﬁ ed information
(DII), 1
Deltasone (prednisone), 148
Dermal puncture procedures,
124–125
Desyrel (trazodone), 149
Detrol (tolterodine), 149
Dexilant (dexlansoprazole), 146
Dexlansoprazole, 146
Dextrose, 143
Diabeta (glyburide), 147
Diazepam, 141, 143
Diazepam (C-IV), 146
Diﬂ ucan (ﬂ uconazole), 146
Digoxin, 142–143, 146
DII (de-identiﬁ ed information), 1
Dilantin (phenytoin), 143
Dilator, 157
Dilators, 153
Diltiazem, 146
Diovan (valsartan), 149
Diphenhydramine (Benadryl),
143
Disclosure, 1, 5–6
Disinfection, 152
Disposal procedures, 56–57
Diuretics, 140
Diuril (chlorothiazide), 143
Documentation, 63–65
SOAP method, 65
Documents, privacy policy, 8–10
Domestic violence, reporting, 7
Donepezil, 146
Dorsal recumbent position, 70
Dosage calculations, 135
Doxycycline, 146
Duloxetine, 146
Dyazide (triamterene/HCTZ),
149
E
Ear, 114
Ears, 86
Effexor (venlafaxine), 149
Elavil (amitriptyline), 145
Electrocardiography, 87–89
Electrolytes, 129
Electronic health records (EHR),
13
E-mails, 22
Emergency drugs, 143
Enalapril, 146
Endocrine system, 110
English-to-Spanish translations,
167–171
Epinephrine, 143
Erythromycin, 141
Escitalopram, 146
Esomeprazole, 146
Estrogen, 146
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198
INDEX
Exercise apps, 104
Explanation of beneﬁ ts (EOB), 35
Externship information,
165–166
Eyes, 82–85
Ezetimibe, 146
F
Famotidine, 146
Fax, 22–23
Fecal occult blood, 80–81
Fenoﬁ brate, 146
Fexofenadine, 146
Filing systems, 14–17
Finger puncture, 125
Five Cs of communication, 18
Flexeril (cyclobenzaprine), 146
Flomax (tamsulosin), 149
Flonase (ﬂ uticasone), 146
Flow rate, intravenous (IV), 135
Fluconazole, 146
Fluoxetine, 146
Fluticasone, 146
Foerster Sprong Clamp, 154
Folic acid, 146
Folvite (folic acid), 146
Food apps, 104
Food–drug interactions, 141–142
Food sources, 99
Forceps, 153
Fosamax (alendronate), 145
Furosemide, 146
G
Gabapentin, 147
GI procedures, 80–82
Glucophage (metformin), 147
Glyburide, 147
Glycemic index, 101–104
Glycemic load, 101
Gonorrhea, 76
Graves Vaginal Speculum, 156
Guthrie Retractor, 156
Gynecological infections, 76
Gynecology exams, 73–76
H
Handwashing, 98
Hank Dilator, 157
HCTZ (hydrochlorothiazide), 147
Health and food apps, 104
Health care operations, 1
Health Insurance Portability and
Accountability Act (HIPAA),
1–3, 11
Health insurance terms, 35
Health maintenance
organization (HMO), 35
Heart, 107
Heel puncture, 125
Hematology and coagulation, 127
Hemostat, 153
Hemostatic clamps, 155
HIPAA, 1–3, 11
Holistic medicine, procedure
codes for, 41
Holter monitor, 90–91
Hospital E/M services,
procedure codes for, 41
Household measures, 134
Hydrochlorothiazide, 147
Hydrocodone/APAP (C-III), 147
Hydrocortisone, 143
Hypertension coding, guidelines
for, 49
I
Ibuprofen, 147
ICD. See International
Classiﬁ cation of Diseases
(ICD)
ID (intradermal) injection, 138
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199
INDEX
IIHI (individually identiﬁ able
health information), 2
IM (intramuscular) injection,
137–138
Immunization
adult, 96–98
birth through 18 years, 79
Incision and draining of
localized infection, 162–163
Individually identiﬁ able health
information (IIHI), 2
Individual patient rights, 3
Infections
bacterial and parasitic
infections, stool collection
for, 130
gynecological, 76
Injections, 137–139i
Instruments, 153–157
Insulin, 147
Integrity, 2
International Classiﬁ cation of
Diseases (ICD), 43–51
common diagnosis codes,
46–48
hypertension coding, 49
ICD-10 chapter list, 44–45
ICD-9-CM transition to ICD-10,
43, 45–46
ICD-10-PCS, 50–51
using the ICD diseases index,
43
Ishihara test for color vision, 84
J
Januvia (sitaglibtin), 149
K
Keﬂ ex (cephalexin), 145
Klonopin (clonazepam) (C-IV),
145
Knee-chest position, 71
KOH preparation for Candida ,
75
K-Tab (potassium), 148
L
Lab tests and normal values,
127–129
Lacerations, suturing, 159–160
Lanoxin (digoxin), 146
Lantus (insulin), 147
Lasix (furosemide), 146
Latanoprost, 147
Law enforcement, disclosures
to, 7
Letters, parts of, 19
Levaquin (levoﬂ oxacin), 147
Levodopa, 141–142
Levoﬂ oxacin, 147
Levothyroxine, 147
Lexapro (escitalopram), 146
Lifting, proper techniques of,
117–118
Limb lead placement, ECG, 88
Lipid proﬁ le, 129
Lipitor (atorvastatin), 145
Liquid measurements, 134
Lisdexamfetamine (C-II), 147
Lisinopril, 147
Lithotomy position, 69
Local anesthetics, 140
Lopressor (metoprolol), 147
Lorazepam (C-IV), 147
Lotensin (benazepril), 145
Lovastatin, 141–142, 147
Lungs, 108–109
Lyrica (pregabalin), 148
M
Mayo-Heger Needle Holder,
155
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200
INDEX
Medical record
components of, 3
electronic, 13
protected health information
(PHI), 3
Medication administration,
135–139
Medications
classiﬁ cation of, 140
common prescription
medications, 145–149
emergency drugs, 143
food–drug interactions,
141–142
prescription abbreviations
and symbols, 144
prescription requirements
for controlled substances,
142
Medrol (methylprednisolone),
147
Meloxicam, 147
Memantine, 147
Metformin, 147
Methotrexate, 141
Methyldopa, 142
Methylphenidate (C-II), 147
Methylprednisolone, 147
Metoprolol, 147
Metric measures, 134
Mevacor (lovastatin), 147
Misspelled words, 20
Mobic (meloxicam), 147
Mometasone, 147
Montelukast, 147
MyPlate, 101
N
Naegele’s rule, 77
Naloxone (Narcan), 143
Namenda (memantine), 147
Naproxen, 147
Narcan (naloxone), 143
Nasal speculum, 156
Nasonex (mometasone), 147
Near visual acuity testing, 84
Needle holders, 153–155
Neglect, reporting, 7
Neurontin (gabapentin), 147
Nexium (esomeprazole), 146
Niaspan (niacin), 148
Nitroglycerin, 143
Norasc (amlodipine), 145
Normal values for lab tests,
127–129
Nose and throat, 115
Notice of privacy practices, 8
Numeric ﬁ ling systems, 16–17
Nutrition, 99–104
O
Obstetrics, 77–78
Occupational Safety and Health
Administration (OSHA),
56–57
Ofﬁ ce or other outpatient E/M,
procedure codes for, 38
Ofﬁ ce tips, 25, 72
Olanzapine, 148
Olmesartan, 148
Omeprazole, 148
Opioid analgesics, 140
Oral contraceptives, 140
Oral medication dosage
calculations, 135
Order of Draw for blood tubes,
122
Organ and tissue transplant/
donation, 7
Outpatient procedures,
procedure codes for, 38–39
Oxycodone/APAP (C-II), 148
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201
INDEX
Oxycodone (C-II), 148
OxyContin (oxycodone) (C-II),
148
P
Pain assessment, 59–60
Pantoprazole, 148
Parasitic infection, stool
collection for, 130
Paroxetine, 148
Patient identiﬁ able information
(PII), 2
Patient interview, 58–60
Patient rights, 3
Paxil (paroxetine), 148
Payment, 2
Pediatrics exams, 78–80
Pedometer apps, 104
Penicillin, 148
Pen VK (penicillin), 148
Pepcid (famotidine), 146
Percocet (oxycodone/APAP)
(C-II), 148
Phenergan (promethazine), 148
Phenobarbital, 141
Phenytoin, 141, 143
Phenytoin (Dilantin), 143
PHI. See Protected health
information (PHI)
Physical examination, 67–71
PII (patient identiﬁ able
information), 2
Pioglitazone, 148
Plavix (clopidogrel), 145
Positioning, 68–71
dorsal recumbent position, 70
knee-chest position, 71
lithotomy position, 69
prone position, 69
semi-Fowler’s position, 70
Sims’ position, 71
sitting position, 68
supine position, 69
Potassium, 148
Pravachol (pravastatin), 148
Pravastatin, 148
Preauthorization, 35
Prednisone, 148
Preferred provider, 35
Pregabalin, 148
Premarin (estrogen), 146
Prenatal visits, 77–78
Prilosec (omeprazole), 148
Primary care provider, 35
Prinivil (lisinopril), 147
Privacy ofﬁ cer job description,
8
Privacy policy documents,
8–10
Privacy standard, 2
ProAir HJA (albuterol), 145
Probes, 153
Probing or dilating instruments,
156–157
Procedural terms, 36–37
Procedure codes, 38–42
allergy testing, 40
alternative/holistic medicine,
41
common outpatient
procedures, 38–39
hospital E/M services, 41
ofﬁ ce or other outpatient
E/M, 38
vaccines, 41
x-rays, 40
Prochlorperazine (Compazine),
143
Promethazine, 148
Prone position, 69
Protected health information
(PHI), 3–6
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202
INDEX
Protonix (pantoprazole), 148
Proton pump inhibitors, 140
Prozac (ﬂ uoxetine), 146
Pulse, 61, 63
Pulse oximeter, 92
Pulse points, 62
Q
Quetiapine, 148
Quinidine, 141
R
Ranitidine, 148
Referral, 35
Reporting victims of abuse, 7
Request for payment, 27–34
Respiration, 61, 63
Retractors, 153, 156
Rhythm strip, 88
Risedronate, 148
Rosuvastatin, 148
S
Sanitization, 152
SC (subcutaneous) injection,
138–139
Scalpel, 153
Schedule planner/organizer,
189–191
Scissors, 153
Scopes, 153
Security standard, 2
Semi-Fowler’s position, 70
Seroquel (quetiapine), 148
Sertraline, 148
Seven rights of medication
administration, 135–136
Sharps containers, 56
Sick child visits, 80
Sims’ position, 71
Simvastatin, 148
Singulair (montelukast), 147
Sitaglibtin, 149
Sitting position, 68
Skeleton, 112
Snellen’s eye chart, 82
SOAP method, 65
Soma (carisoprodol) (C-IV), 145
Spanish-to-English translations,
167–171
Specimens, collecting and
handling, 130–131
Speculum, 153
Spills, biohazard, cleaning up,
57
Spiriva (tiotropium), 149
Spirometry, 92
Sprong clamps, 154
Sputum collection, 130
Standard precautions, 56–57
Sterilization, 152
Steroids, 140
Stool collection, 130
Suboxone (buprenorphine)
(C-111), 145
Supine position, 69
Surgery, ofﬁ ce, 152–163
autoclave procedure, 153
incision and draining of
localized infection, 162–163
instruments, 153–157
surgical asepsis, 152–153
sutures, 158–161
Sutures, 158–161
Synthroid (levothyroxine), 147
T
Tamsulosin, 149
Telephone communication,
20–22
Temperature, 61–62
Tenormin (atenolol), 145
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203
INDEX
Termination procedure, 8
Terminology, medical,
180–188
Test kits, 126
Tetracycline, 141
Throat culture collection,
131
Thyroid panel, 129
Tiotropium, 149
Tolterodine, 149
Towel clamps, 154
Tramadol, 149
Travel immunizations, 98
Trazodone, 149
Treatment, deﬁ nition of, 2
Triamterene/HCTZ, 149
Trichomonas , 74, 76
TriCor (fenoﬁ brate), 146
Tylenol # 2 (codeine/APAP)
(C-III), 146
U
Ultram (tramadol), 149
Urinalysis, 129
Urinary system, 111
Use, deﬁ nition of, 3
Utilization review, 35
V
Vaccines, 41
Vaginal speculum, 156
Valium (diazepam) (C-IV), 146
Valsartan, 149
Vasotec (enalapril), 146
Venipuncture, routine,
120–123
common sites, 121
order of draw for blood
tubes, 122
tube colors, 123
Venlafaxine, 149
Veriﬁ cation, 35
Vibramycin (doxycycline), 146
Visual acuity testing for
distance, 82–83
Vital signs, 61–63
Vyvanse (lisdexamfetamine)
(C-II), 147
W
Warfarin, 141–142, 149
Waste containers, 56
Webster Needle Holder, 155
Weight and body mass index
(BMI), 100
Words, misspelled, 20
Work-related illnesses and
accidents, 7
Written communication, 18–20
X
Xalatan (latanoprost), 147
Xanax (alprazolam) (C-IV), 145
X-rays, procedure codes for, 40
Z
Zantac (ranitidine), 148
Zetia (ezetimibe), 146
Zithromas (azithromycin), 145
Zocor (simvastatin), 148
Zoloft (sertraline), 148
Zolpidem (C-IV), 149
Zyloprim (allopurinol), 145
Zyprexa (olanzapine), 148
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