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It should always be made clear when billing insurance companies exactly what condition has been treated. The ICD numbers cover all conditions; if unsure of exactly what condition has been treated, consult with the treating physician.
When answering a telephone in a formal situation, give both the name of the office/institution and your name: “Smith Clinic, Jane Doe speaking, how can I help?” This lets the caller know they have reached the right place and creates a human relationship between you.
A catheter is used to drain fluid from the body. It may be inserted in a body cavity, duct or vein.
Tiny particles of oil suspended in fluid are known as an emulsion. Examples are cod liver oil and castor oil (taken orally) and many types of skin cream.
Autoclaves must be used with distilled water. Most modern autoclaves have purity sensors that will abort the sterilization procedure if distilled water is not used. Even if your machine does not have a purity sensor, using even boiled water will risk compromising the effectiveness of sterilization and greatly increase the need for cleaning – it may even damage the machine.
Palpation means to feel for lumps and abnormalities with the fingers, for example feeling to see if any organs are swollen. A palpation examination should be undertaken with great care for the sensitivities of the patient, and what you are doing should be carefully explained beforehand.
All vital signs should be carefully monitored during an ECG test and the test should be suspended or aborted if a patient begins to show obvious signs of distress.
Analgesic drugs are used for pain management. Analgesics can range from mild, e.g. aspirin, to extremely strong, e.g. opiate drugs. They may be either narcotic or nonnarcotic. Care must be taken with all analgesic drugs as they can be damaging or fatal in overdose and many can be addictive.
To eliminate errors and omissions, whenever possible new data should be added as it is provided by the patient or other entity. This minimizes the chance of the data being lost or forgotten. If it is not possible immediately to update the database, there should be a procedure in place for safe recording of data manually until the database can be updated.
As an ECG machine passes electricity through a patient every care must be taken to ensure that the patient does not receive an excessive charge. Ensuring the machine is properly grounded means that any accidental charge should be drawn away from the patient.
Fax machines are not regarded as a secure method of communication as misdialing can result in the fax going to unintended recipients; also fax machines are often in public areas and not continually monitored. For this reason you must obtain a patient's permission if you wish to send their records by fax.
The median cubital vein is located in the forearm, running through the middle of the crook of the elbow. Always remember that although it is the best vein to use in normal healthy adults, all patients are different and other veins may offer a better opportunity for a successful blood draw.
The chain of custody dictates the way in which a sample will be taken and how it will be guarded against tampering before, during and after testing. Make sure you know the regulations in place and follow them closely, otherwise you may be called upon to explain why you did not.
Respondeat superior translates as “let the master answer” and means that an employer can be held responsible for an employee’s actions, provided those actions come under the heading of their employment, for example a clinic may be held accountable for a medical practitioner’s negligence. However, this does not mean that employees will necessarily escape sanction for malpractice or negligence: both employer and employee can be sanctioned.
"Tickler" systems send out automatic appointment reminders to patients, either through automatically issued letters, emails, SMS or automated telephone calls. There will be a default setting for when and how often these will be sent out, but you should be aware of any patients who for some reason may need more frequent or more personal reminders.
Medical etiquette refers to what is regarded as socially acceptable behavior for medical practitioners. Examples might be how a patient is spoken to, the body language employed by a medical practitioner etc. Medical etiquette is not as binding as, and is separate from, medical ethics and law, but it is still regarded as a very important part of being a medical practitioner.
Material Safety Data Sheets (MSDS) should be kept for all material supplies in a medical office (e.g. bio-hazardous materials, radioactive materials). They should be regularly updated to show that correct safety procedures are being followed.
Although all the other entities may request copies of the patient's medical records, they have been created by the care provider (i.e. a medical office, hospital etc.) and remain their property. This means that a care provider is entitled to levy a reasonable charge for the provision of copies of the records.
The ideal situation in a medical environment is for it to be sterile, but in practice this is virtually impossible to achieve, as even healthy people carry bacteria with them. Therefore the aim of cleaning procedures in hospitals is to achieve asepsis (which is also used as a term for the procedures), which means there are no disease causing agents present. Medical asepsis such as would be used on a ward aims to reduce the number of disease-causing organisms, whereas surgical asepsis as used in theatre aims to eliminate them.
In order to ensure your hands are thoroughly clean you should wash them for at least a minute when using soap and water. All parts of the hand should be thoroughly cleaned and rinsed in cold water, dried with a single use towel and you should not touch the faucet with your clean hands when finished.
