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257 Cards in this Set
- Front
- Back
Clinical laboratory improvement and amendment CLIA |
Sets quality standards an issues certificate for human clinical laboratories |
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Health insurance portability and accountability Act. (HIPAA). The right to expect, review, and to receive a copy of your medical records and Billing records that are held by health plans and healthcare provider covered by the privacy rule. Has 2 main purpose
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1. To provide continuous health insurance coverage for workers who lose or change their job. 2. To reduce the administrative burdens and cost of healthcare by standardizing the electronic transmission of administrative and financial transactions and protects the patients personal medical information and confidentiality. A CCMA cannot disclose any patient information unless authorized.
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The joint commission |
Regulated that correctly identifying patients is crucial to improving patient safety |
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Occupation safety and health administration (OSHA) |
1. Federal agency that oversees and regulated safety in the workplace. 2. Training provided at no cost to the employee |
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Quality control (QC) |
Promote accurate test results |
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Patient identification |
1. Always ask patients to confirm their full name and date of birth 2. Never confirm patients name by speaking their name and date of birth to them. If they are not listening or hear they could say yes |
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Implied consent |
1. Extending arm for phlebotomy. 2. Removing clothing for medical procedure or examination |
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Informed Consents |
Information the patient of the risk, possible outcomes, and alternative therapies. |
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Written Contents |
Much have a patients signature to perform the procedure. |
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Patient bill of rights, A list of guarantee for those receiving medical care. |
1. Patients have the right to a copy of the medical records. 2. Guarantees fair treatment 3. Autonomy over medical decisions and many more rights |
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Problem Oriented medical records (POMR) |
Should always be filled out in chronological order |
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Patients have the right to view their medical records at any time |
1. The information contained within the medical record belongs to the patient. The physical form where the information is house belongs to the author |
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CMS-1500 Center for Medicare and Medicaid service |
Basic standard claim form used by healthcare professional to request reimbursement for services provided to patient |
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Encounter form or superbill |
An itemized form of services submitted to insurance carriers for reimbursement of rendered services, A CCMA Would also use this form to check patient out after an office visit |
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Release of information form |
Allow patient access to his own medical records and allows the patient control over to whom those records are released |
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Preferred provider organization (PPO) |
Managed care organization of providers, hospitals, other healthcare providers who have a greed with an insurer or a third party administrator to provide health care at reduced rate to the insurer |
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Medicaid |
Provide health insurance for the medically needy |
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Medicare |
Federal insurance plan covers of the age of 65 and Oder or have paid into the system through payroll tax |
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Tricare |
Healthcare for military personnel and their independence to receive care from civilian providers at the expense of the Federal government |
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Workers Compensation |
Wage replacement and medical benefits for those injured on the job |
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Advance beneficiary notice (ABN) |
Waiver of liability, is a notice a provider should give you before you receive the service |
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Copay |
Specific sum of money based on their patients insurance policy benefits due at the time of service |
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Coincidence |
An amount a policyholder is financially responsible for according to their insurance policy. Policyholders must meet a specified amount before the insurance company will pay their portion. |
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Modified |
Indicate one procedure was use multiple times on a patient |
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Scheduling.
Advance booking. making an appointment for patient in advance. Clustering. seeing patients on the same day at the same time. Double booking. two patients are given the same appointment time. Hard of hearing or deaf patients. get an interpreter. Late provider. offered to reschedule a patient’s appointment if the provider is late. |
New patience NP. a patient who had not been seen by the provider before Or who has not been seen in three or more years is considered a new patient for coding and billing purposes. No show ns. patients who have missed their schedule appointment. Tests. schedule the least invasive test first if a patient is having multiple tests. Wave schedule. three or four patients are scheduled every half hour and or seen in the order in which they arrive in the office. |
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Aerophagia |
Swallowing air |
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Alopecia |
Sudden increased hair loss |
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Anthropometric |
Used to assess the size, shape, and composition of the human body e.g BMI or a growth chart |
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Chief complaint cc |
The primary symptom that a patient states as the reason for seeking medical care |
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Cirrhosis |
Chronic liver disease |
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Cholecystectomy |
Removal of the gallbladder |
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Dysuria |
Painful or difficult urination |
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Coinsurance |
An amount a policyholder is financially responsible for account to their insurance policy. The policyholder must meet amount before the insurance company will pay their portion |
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Dextrocardia |
The heart points to the right side instead of the left |
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Electronica health record EHR |
Electronica record of patient’s health related information and can be created, manage, and access from multiple healthcare organization Also always back up the information on the storage device |
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Electronica medical record EMR |
Electronica record of patient’s health related information and can be create, manage, and access within a single health care organization Also always back up the information on storage device |
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Hemostasis |
Promote coagulation and stops bleeding |
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Hypoglycemia |
Low blood sugar that can be helped by giving the patient orange juice |
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Cardiologist |
Diagnoses and treats disease of the heart |
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DO doctors of Osteopathy |
Similar to medical doctors, but have a holistic approach. |
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Endocrinologist |
Treats patients who suffer from hormonal imbalances. Treats diabetes, thyroid disorders, pituitary disorders, and other hormonal disease |
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Deductible |
Specific amount of money a patient must pay out of pocket before the insurance carrier begins paying for the servers in a calendar year |
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Explanation of benefits (EOB) |
A statement detangling what service were paid, denied, or reduce in payment by the patient insurance company |
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Preauthorization |
A decision by your health insurance or plan that healthcare service, treatment plan prescription drugs, or durable medical equipment is medically necessary |
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Percertification |
The process of obtaining eligibility, certification or Authorization and collecting information from the health plan prior to the impatient admissions and selected ambulatory procedure and service |
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Referral |
The process of directing or redirecting to a medical specialist or agency for definitive treatment |
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Vilification of eligibility |
Before your provide care, it is important to confirm how patient will pay for service. It is equally important to verify a patient’s insurance eligibility before you provide any care |
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CPT |
Current procedural terminology |
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ICD |
International classification of diseases Each diagnostic and procedural code allows for submission of service for reimbursement from insurance companies and to provide statistics data for research studies |
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Nurse practitioners NP |
Advanced academic training beyond the registered nurse RN |
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Orthodontist |
Concerned with correction of deformities or functional impairment of the skeletal system |
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Pathologist |
Study cause and effect of disease, perform autopsies, and analyze tissue sample |
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Physician’s assistant |
Practice medicine under the direction and supervision of a licensed medical doctor MD |
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Radiology |
The science dealing with x-rays and other high energy radiation, especially the use of such radiation for the diagnosis and treatment of disease |
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Dorsal recumbent |
Lying flat on the back with knees bents |
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Radiology |
The science dealing with x-rays and other high energy radiation, especially the use of such radiation for the diagnosis and treatment of disease |
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Fowlers |
Upright sitting position with the exam table raised to a 90 degree angle Best position to help patient who have difficulty breathing |
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Dorsal recumbent |
Lying flat on the back with knees bents |
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Lithotomy |
Lying flat on the table with buttocks at the end of the table and feet resting in stirrups |
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Dorsal recumbent |
Lying flat on the back with knees bents |
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Prone |
Lying flat on the abdomen with the arms above the head |
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Supine |
Lying flat on the back with the arms down to the side 1. Used for doing an EKG 2. Measuring an infant 3. Any procedure that requires a patient to be lying on their back |
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Sim (lateral) |
Lying on the left side with the leg slightly flexed and the right leg flexed at a 90 degree angle Exams involving the rectum and administrating enemas |
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Trendelenburg |
Legs elevated above the head to force circulation to vital organs. Effective in raising a patient’s low blood pressures. |
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Coronal/frontal |
Divides the body into anterior and posterior section. |
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Sagittal |
Divides the body into left and right |
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Transverse |
Divides the body into top (superior) and bottom (inferior) party |
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Body mass index BMI |
Calculate by height and weight |
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Cardiopulmonary resuscitation CPR |
100 compression should be performed in one minute |
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Eye irrigation |
To relieve inflammation and discomfort |
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Figure eight bandage |
Typically used to wrap the ankle |
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Ischemic |
Restrictions of oxygen rich blood to a portion of the body |
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Parathyroid hormone |
Hormone secreted by the parathyroid glad that is important in bone growth Associated with the regulation of calcium in the body. |
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Patient centered care |
Requires the inclusion of both family and patient regarding the patient care |
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Pericarditis |
Inflammation of the pericardium (surrounding lining of the heart) |
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Personal protective equipment PPE |
Equipment that protects the wearer from bodily injury or infection. OHSA mandate that PPE be free of charge |
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Petechiae |
Broken capillaries due to bleeding under the skin. One reason is too tight a tourniquet |
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Pyelonephritis |
Inflammation of the kidney which can cause pain in the lower and mid back. |
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Retinopathy |
Disease of the retina that results In impairment or loss of vision and can be complication of diabetes mellitus. |
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Vertigo |
Episodes of dizziness and sensation of spending with the certain head movements. 1. Caused by an inner ear disorder 2. Can be caused by performing an ear irrigation on a patient. |
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SOAP note |
A format for communicating important patient information in a chart in an organized manner Subjective. information the patient conveys Objective. measurable information about the patient (vitals, diagnostic findings, ect) Assessment. a detailed examination by the provider to determine health status. Plan. a series of proposed intervention to improve health or treat disease. |
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Vertigo |
Episodes of dizziness and sensation of spending with the certain head movements. 1. Caused by an inner ear disorder 2. Can be caused by performing an ear irrigation on a patient. |
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Spirometey |
Common office test used to assess how well your lugs work by measuring how much are you inhale, how much you exhale, and how quickly you exhale 1. Requires two maneuvers. |
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Vertigo |
Episodes of dizziness and sensation of spending with the certain head movements. 1. Caused by an inner ear disorder 2. Can be caused by performing an ear irrigation on a patient. |
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Spirometey |
Common office test used to assess how well your lugs work by measuring how much are you inhale, how much you exhale, and how quickly you exhale 1. Requires two maneuvers. |
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Syncope |
Fainting which can exhale as dizziness, lightheadedness and ringing in the ears |
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Spirometey |
Common office test used to assess how well your lugs work by measuring how much are you inhale, how much you exhale, and how quickly you exhale 1. Requires two maneuvers. |
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Transition of care |
Refers to the coordination and continuity of health care during a movement of a patient from one healthcare setting to another or to home. |
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ABGs |
Arterial blood gases |
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Cbc |
Complete blood count |
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CC |
Chief complaint |
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Dys |
Difficult, painful |
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-Ectomy |
Surgical removal |
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itis |
Inflammation |
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Nephe/o |
Kidneys |
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Ology |
Study of |
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Ophth |
Eye |
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Oto |
Ear |
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PE |
Physical examination |
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R.O.M |
Range of motion |
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STI |
Sexually transmitted infections |
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UA |
Urinalysis |
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BP |
Blood pressure |
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CXR |
Chest x Ray |
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Derm |
Skin |
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CABG |
Coronary artery bypass graft |
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I and O |
Intake and output |
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K |
Potassium |
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NS |
No show |
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O2 |
Oxygen |
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OTC |
Over the counter |
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Plasty |
Surgical reconstruction |
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PO |
By mouth |
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STAT |
Immediately |
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TB |
Tuberculosis |
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UTI |
Urinary tract infection |
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Infant head measurement |
Place tape measure at the most prominent part of the forehead, often one to two fingers aboveboard the eyebrows. |
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Ishihara eye chart |
Test for color vision |
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Pulse oximetry |
Measuring the oxygen level in the blood Place on fingers or ear lobe |
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Streptococcus test |
Collected from the throat (oral) |
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Stress test |
Monitor cardiovascular capacity during a period of increasingly strenuous exercises while the patient is using a treadmill. Patient sweating is normal test should be continued with no interruption |
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Transferring a patient |
Is always a concern so as not to injure the patient or the healthcare worker Always use correct body mechanics, like bending at the knees when lifting |
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Vision test |
Visual acuity chart that is used to test distance visual acuity. It use capital letters of different size to test vision on the literate adult. The test is conducted from 20 feet away |
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Weighing a patient |
Perform quality control QC on a scale by balancing the scale first before weighing a patient |
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Wound care |
Always clean in a circular motion from inward to outward If a wound culture is taken, then include in the documentation any recent patient use of antibiotics |
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Standard precaution |
Set of infection control practices used to prevent transmission of disease. Basically treat everyone as if they are infected |
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Transmission Methods |
1. Airborne, influenza, measles, tuberculosis 2. Blood-borne, human immunodeficiency virus (HIV) 3. Contact, sexually transmitted illnesses (STIs) |
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Ophthalmoscope |
Used to examine and see inside the structure of the eye. |
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Otoscope |
Used to look into the ear |
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Sphygmomanometer |
Is an Instrument used to measure blood pressure |
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Weighing |
If a patient is having difficulty standing then have them use a walker by placing the walker over the scale |
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Anatomy |
The study of the structure of living things |
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Physiology |
Function and processes of living organism |
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Red blood cell, erythrocyte, RBC |
Transports oxygen throughout the body. |
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Platelets, thrombocytes |
Function is to stop bleeding by clumping and clotting vessel injury |
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White blood cell, leukocyte, wbc |
Cells of the immune system that are involved in protecting the body. Least prevalent of these are basophils comprising less than 1% of white blood cells. Neutrophils account for roughly 60% of white blood cells. |
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Caution |
1. Gloves should always be worn if there is a risk of exposure to bodily fluids such as urine, blood, cysts, pus, ets 2. Sharps container A hard plastic container that is used to safely dispose of needles and other sharp objects. Always log removal in a facility logbook |
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Sharps container |
A hard plastic container that is used to safety dispose of needles and other sharp objects. Always log removal in a facility log book. |
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Sharps container |
A hard plastic container that is used to safety dispose of needles and other sharp objects. Always log removal in a facility log book. |
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Crohns diseases |
A type of inflammation bowel disease. Has an underlying genetic cause; provider should screen for family history. |
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Sharps container |
A hard plastic container that is used to safety dispose of needles and other sharp objects. Always log removal in a facility log book. |
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Crohns diseases |
A type of inflammation bowel disease. Has an underlying genetic cause; provider should screen for family history. |
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Graves disease |
An autoimmune disease that affects the thyroid. Smoking may increase the risk of disease and may worsen eye problems. |
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Sharps container |
A hard plastic container that is used to safety dispose of needles and other sharp objects. Always log removal in a facility log book. |
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Crohns diseases |
A type of inflammation bowel disease. Has an underlying genetic cause; provider should screen for family history. |
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Graves disease |
An autoimmune disease that affects the thyroid. Smoking may increase the risk of disease and may worsen eye problems. |
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Illness |
Subjective departure from wellness. |
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Sharps container |
A hard plastic container that is used to safety dispose of needles and other sharp objects. Always log removal in a facility log book. |
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Crohns diseases |
A type of inflammation bowel disease. Has an underlying genetic cause; provider should screen for family history. |
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Graves disease |
An autoimmune disease that affects the thyroid. Smoking may increase the risk of disease and may worsen eye problems. |
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Illness |
Subjective departure from wellness. |
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Influenza |
A common viral infection that can be deadly, especially in high risk groups. Body aches, sore throat, coughing, fever, runny nose, and feeling tired. |
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Pharmacology |
The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties. |
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Pharmacology |
The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties. |
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Antipyretics |
Medication used to lower a patient body temperature |
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Pharmacology |
The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties. |
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Antipyretics |
Medication used to lower a patient body temperature |
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Absorption |
How long it takes for a drug to get into the bloodstream. |
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Pharmacology |
The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties. |
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Antipyretics |
Medication used to lower a patient body temperature |
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Absorption |
How long it takes for a drug to get into the bloodstream. |
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Contraindications |
A specific situation in which a drug should not be used because it may be harmful to the patient. |
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Pharmacology |
The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties. |
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Antipyretics |
Medication used to lower a patient body temperature |
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Absorption |
How long it takes for a drug to get into the bloodstream. |
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Contraindications |
A specific situation in which a drug should not be used because it may be harmful to the patient. |
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Distribution |
The reversible transfer of a drug from one location to another within the body. |
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Pharmacology |
The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties. |
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Antipyretics |
Medication used to lower a patient body temperature |
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Absorption |
How long it takes for a drug to get into the bloodstream. |
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Contraindications |
A specific situation in which a drug should not be used because it may be harmful to the patient. |
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Distribution |
The reversible transfer of a drug from one location to another within the body. |
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Excretion |
The removal of a medication from the body. |
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Pharmacology |
The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties. |
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Antipyretics |
Medication used to lower a patient body temperature |
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Absorption |
How long it takes for a drug to get into the bloodstream. |
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Contraindications |
A specific situation in which a drug should not be used because it may be harmful to the patient. |
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Distribution |
The reversible transfer of a drug from one location to another within the body. |
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Excretion |
The removal of a medication from the body. |
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Indication |
A condition which makes a particular treatment or procedure advisable. |
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Pharmacology |
The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties. |
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Antipyretics |
Medication used to lower a patient body temperature |
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Absorption |
How long it takes for a drug to get into the bloodstream. |
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Contraindications |
A specific situation in which a drug should not be used because it may be harmful to the patient. |
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Distribution |
The reversible transfer of a drug from one location to another within the body. |
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Excretion |
The removal of a medication from the body. |
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Indication |
A condition which makes a particular treatment or procedure advisable. |
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Metabolism |
Most important organ for drug metabolism is the liver. |
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Pharmacology |
The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties. |
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Antipyretics |
Medication used to lower a patient body temperature |
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Absorption |
How long it takes for a drug to get into the bloodstream. |
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Contraindications |
A specific situation in which a drug should not be used because it may be harmful to the patient. |
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Distribution |
The reversible transfer of a drug from one location to another within the body. |
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Excretion |
The removal of a medication from the body. |
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Indication |
A condition which makes a particular treatment or procedure advisable. |
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Metabolism |
Most important organ for drug metabolism is the liver. |
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Bronchodilator |
Dilates the bronchi and bronchioles by decreasing resistance in the respiratory airway and increasing airflow to the lungs. Should stop using before a patient is scheduled for a pulmonary function test. |
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Pharmacology |
The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties. |
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Antipyretics |
Medication used to lower a patient body temperature |
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Absorption |
How long it takes for a drug to get into the bloodstream. |
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Contraindications |
A specific situation in which a drug should not be used because it may be harmful to the patient. |
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Distribution |
The reversible transfer of a drug from one location to another within the body. |
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Excretion |
The removal of a medication from the body. |
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Indication |
A condition which makes a particular treatment or procedure advisable. |
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Metabolism |
Most important organ for drug metabolism is the liver. |
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Bronchodilator |
Dilates the bronchi and bronchioles by decreasing resistance in the respiratory airway and increasing airflow to the lungs. Should stop using before a patient is scheduled for a pulmonary function test. |
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Enteric Coates tablets |
Contain an outer shell that prevents an oral tables from dissolving until reaches the intestines, often to prevent stomach irritation. |
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Pharmacology |
The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties. |
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Influenza vaccine |
Must document expiration date and lot number in patient medical record. |
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Antipyretics |
Medication used to lower a patient body temperature |
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Absorption |
How long it takes for a drug to get into the bloodstream. |
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Contraindications |
A specific situation in which a drug should not be used because it may be harmful to the patient. |
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Distribution |
The reversible transfer of a drug from one location to another within the body. |
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Excretion |
The removal of a medication from the body. |
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Indication |
A condition which makes a particular treatment or procedure advisable. |
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Metabolism |
Most important organ for drug metabolism is the liver. |
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Bronchodilator |
Dilates the bronchi and bronchioles by decreasing resistance in the respiratory airway and increasing airflow to the lungs. Should stop using before a patient is scheduled for a pulmonary function test. |
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Enteric Coates tablets |
Contain an outer shell that prevents an oral tables from dissolving until reaches the intestines, often to prevent stomach irritation. |
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Pharmacology |
The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties. |
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Influenza vaccine |
Must document expiration date and lot number in patient medical record. |
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Opiates |
Drugs with morphine like effects, derived from opium to treat pain. |
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Antipyretics |
Medication used to lower a patient body temperature |
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Absorption |
How long it takes for a drug to get into the bloodstream. |
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Contraindications |
A specific situation in which a drug should not be used because it may be harmful to the patient. |
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Distribution |
The reversible transfer of a drug from one location to another within the body. |
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Excretion |
The removal of a medication from the body. |
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Indication |
A condition which makes a particular treatment or procedure advisable. |
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Metabolism |
Most important organ for drug metabolism is the liver. |
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Bronchodilator |
Dilates the bronchi and bronchioles by decreasing resistance in the respiratory airway and increasing airflow to the lungs. Should stop using before a patient is scheduled for a pulmonary function test. |
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Enteric Coates tablets |
Contain an outer shell that prevents an oral tables from dissolving until reaches the intestines, often to prevent stomach irritation. |
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Pharmacology |
The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties. |
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Influenza vaccine |
Must document expiration date and lot number in patient medical record. |
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Opiates |
Drugs with morphine like effects, derived from opium to treat pain. |
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Non-steroidal anti-inflammatory drug (NSAID) |
Reduces pain and inflammation. |
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Antipyretics |
Medication used to lower a patient body temperature |
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Absorption |
How long it takes for a drug to get into the bloodstream. |
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Contraindications |
A specific situation in which a drug should not be used because it may be harmful to the patient. |
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Distribution |
The reversible transfer of a drug from one location to another within the body. |
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Excretion |
The removal of a medication from the body. |
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Indication |
A condition which makes a particular treatment or procedure advisable. |
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Metabolism |
Most important organ for drug metabolism is the liver. |
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Bronchodilator |
Dilates the bronchi and bronchioles by decreasing resistance in the respiratory airway and increasing airflow to the lungs. Should stop using before a patient is scheduled for a pulmonary function test. |
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Enteric Coates tablets |
Contain an outer shell that prevents an oral tables from dissolving until reaches the intestines, often to prevent stomach irritation. |
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Pharmacology |
The study of medications and how they act on the body, (both good and bad), as well as their classification and various properties. |
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Influenza vaccine |
Must document expiration date and lot number in patient medical record. |
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Opiates |
Drugs with morphine like effects, derived from opium to treat pain. |
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Non-steroidal anti-inflammatory drug (NSAID |
Reduces pain and inflammation |
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Transdermal patches |
Adheres to patients skin and the medication is absorbed slowly. Instruct the patient to write the date and time on each patch that is applied. |
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Antipyretic |
Medication used to lower a patient body temperature |
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Absorption |
How long it takes for drug to get into the bloodstream. |
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Contraindication |
A specific situation in which a drug should not be used because it may be harmful to the patient. |
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Distribution |
The reversible transfer of a drug from one location to another within the body. |
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Excretion |
The removal of a medication from the body. |
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Indication |
A conditioner which makes a particular treatment or procedure advisable. |
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Metabolism |
Most important organ for drug metabolism is the liver. |
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Bronchodilator |
Dilates the bronchi and bronchioles by decreasing resistance in the respiratory airway and increasing airflow to the lungs. Should stop using before a patient is scheduled for a pulmonary function test. |
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Enteric Coated Tablets |
Contain an outer shell that prevent an oral tablet from dissolving until it reaches the intestines, often to prevent stomach irritation. |