Current procedural terminology (CPT) pronounced “captain” is how healthcare providers communicated their services to insurance companies. When collecting histories ask the seven questions required by CPT.
The International Classification of Diseases (ICD) are diagnosis codes that allow all healthcare providers to communicate with each other.
Government and Institutional Rules and Regulations
The Health Insurance Portability and Accountability Act (HIPAA) – This act protects patients personal health information.
Occupational Safety and Health Administration (OSHA) – OSHA enforces safety in the workplace. Eye protection in the workplace is an example of an OSHA enforced policy. All work places must have an OSHA posters which explains the employees right to work in a safe environment.
Federal Trade Commission (FTC) – The FTC helps keep consumers safe from fraud. The FTC helps people to avoid identity theft and dishonest transactions.
Quality assurance is making sure that the service provided to patients are always good. Quality assurances tests things that are measurable, things that can produce data. Visual acuity after a surgery would be an example of quality assurance. It is important for practices to develop and maintain quality assurance programs to maintain a high standard of care.
Ethical and Legal Standards
Ethics is a branch of philosophy which concerns what one ought to do. What is morally right. The Hippocratic Oath, “Do no harm” is the basis of ethics in medicine. This states that the right thing to do in medicine is the thing which causes the least harm to the patient. This is a questions more for the practitioner than for the technician. What we as techs encounter more is scope of practice.
Scope of practice is the legal bounds which every healthcare worker must work. For example, I can refract a patient, but it would be outside of my scope of practice to give the patient a prescription for glasses. Writing a prescription for glasses is within an optometrists scope of practice.
A scribe is the personal assistant to the practitioner. Scribes save the practitioner time by recording exam findings, recording diagnosis, and explaining treatment to patient.
The one things to remember with confidentiality is that you should not share information about a patient unless that person is the practitioner responsible for that patient or the patient gives permission for the information to be shared.
Informed consent means that the patient is giving their consent for a treatment based on full knowledge that the physician gives to the patient. Thus the patient know being informed gives consent for the treatment.
Informed consent includes these three parts
- Discussion of potential risks and benefits
- Description of the procedure
- Other treatments available to the patient
This is not an official JCAHPO subsection. I feel it is very important and worth studying.
Medicare – Medicare is an insurance program which serves those who are over 65 regardless of income.
Medicaid– Medicaid is an assistance program which serves low income people of every age.
Workers’ Compensation– This is insurance which covers workers for work related injuries.
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