| AAMA (American Association of Medical Assistants) | A national association providing continuing education, professional networking opportunities, and certification examinations to its members.
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| abandonment | The physician's failure to furnish care for a particular illness for as long as it is required unless the patient has been discharged in an appropriate manner.
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| absolute accuracy | Correctness that is 100 percent; correct-ness without error, required for handling financial transactions.
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| accepting assignment | The agreement by a healthcare provider who participates in an insurance plan to accept the allowed charge as payment in full for services.
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| accession book | A book containing a list of consecutive num-bers used to assign each patient a number in practices where a numeric filing system is used; see also numeric filing.
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| accounting | A system used to classify, record, and summarize financial transactions.
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| accounts payable (A/P) | The unpaid amounts of money owed by the practice to creditors and/or suppliers.
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| accounts receivable (A/R) | The unpaid amounts of money owed to the medical practice by patients and third-party payers.
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| accrual method | The accounting method whereby income is recorded as soon as it is earned, whether or not payment is received; expenses are recorded when they are incurred.
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| accuracy | Correctness, including attention to detail; the trait often ranked most important in assistants by physicians.
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| active files | Those records belonging to patients currently see-ing the physician.
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| administrative medical assistant | The title given to medical office professionals who perform administrative tasks in a wide variety of settings.
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| agenda | An outline of a meeting, specifying location, time, date, and major topics to be discussed.
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| aging reports | Reports that show the passage of time between the issuing of a request for payment (invoice) and the receipt of payment; used to determine late payments and collect them.
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| AHDI (Association for Healthcare Documentation Integrity) | A national organization that promotes professional standards and growth for the field of medical transcription.
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| AHIMA (American Health Information Management Association) | A national organization that serves health information management professionals, keeps professionals current with legislation, and provides consumers of health services with topics of interest to them.
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| allowed charge | The maximum amount that an insurer will pay for a service or procedure; also called "allowable," "maximum."
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| alphabetic filing | A system of filing whereby documents are kept according to names, titles, or classifications in alphabetic order.
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| AMT (American Medical Technologists) | A national organization that promotes professional standards and growth; certification available through the association's examination.
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| annotate | The act of making notes that are either helpful or necessary in the margins of communications before forwarding them to the physician.
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| annual summary | A report providing the monthly charges and payments for an entire year.
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| application software | Computer programs that apply the computer's capabilities to specific uses, such as word processing, graphics, database management, and spreadsheets.
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| arbitration | The process whereby a neutral third party judges the merits of a complaint by one party against another, with the consent of the parties; serves as an alternative to trial and the judgment is binding.
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| ARMA (Association of Records Managers and Administrators) | An international association that includes among its members information managers, archivists, librarians, and educators; sets standards for filing, record retention, and other aspects of records management.
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| assault | The clear threat of injury to another.
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| assertiveness | The ability to step forward to make a point in a confident, positive manner.
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| assessment | The physician's interpretation of subjective and objective findings as contained in the SOAP record; also called "diagnosis" or "impression."
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| assignment of benefits | The permission given by a policy-holder that allows a third-party payer to pay benefits directly to the healthcare provider.
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| audit | A review of all financial data by an independent party outside the practice—the IRS or an accountant—to ensure the accuracy and completeness of all financial transactions.
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| authoritarian/autocratic | A leadership style that provides clear and definitive expectations to team members.
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| authorization | Expressed (stated) permission given by the physician and required to convey information about a patient to anyone (including the patient).
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| balance billing | Collecting payment from the insured patient of the difference between a provider's usual fee and a payer's lower allowed charge.
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| balance sheet | A report for a stated period indicating the practice's complete assets, liabilities, and capital.
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| bank reconciliation | The process of comparing the balance on the monthly bank statement with the checkbook balance to determine whether there is agreement or a difference in the amounts.
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| basic insurance plan | A policy that generally includes coverage of hospitalization, laboratory tests, surgery, and x-rays.
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| battery | Any bodily contact without permission; in medicine, interpreted to include procedures performed without the patient's consent or those that go beyond the degree of consent given.
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| bibliography | A list of all references used by an author in the preparation of a manuscript; listed in a separate section at the end of the text.
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| bioethics | The branch of ethics that deals specifically with medical treatment, technology, and procedure; see also ethics.
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| birthday rule | A guideline for determining which of two parents with medical coverage has the primary insurance for a child; states that the policy held by the insured with the earliest birthday in the calendar year is the primary policy.
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| blank endorsement | The presence of only a signature to enable a check to be cashed or deposited; the most common form of endorsement.
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| block-style letter | Arrangement of a letter so that all lines, including those beginning new paragraphs, begin at the left margin.
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| Blue Cross and Blue Shield Association (BCBS) | One of the largest private-sector insurers in the United States; offers both indemnity and managed care plans with many variations.
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| bookkeeping | The accurate recording of financial transactions.
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| Bound Printed Matter | The classification of mail used for any material permanently bound by materials such as glue, staples, or spiral binding; at least 90 percent of the mailed materials must be imprinted materials composed by means other than handwriting; or typewriting; items may weigh up to 15 pounds and cost is determined by weight, distance, and shape.
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| capitation | A form of payment made by the insurance company in advance of medical services received; the prepayment by the insurance carrier of a fixed amount to a physician to cover services for a member of a particular plan.
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| carrier | An insurance company; also known as a third-party payer.
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| cash basis | The system of accounting whereby charges for services are not recorded as income to the practice until payment is received and expenses are not recorded until they are paid.
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| CD-ROM drive | An optical storage medium using a compact disk (CD); read only memory (ROM) means that the disk cannot record information but may be used to copy new programs onto the hard drive or to store information.
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| Centers for Medicare and Medicaid Services (CMS) | The federal agency responsible for setting up the terms of Medicare and reviewing managed care plans that want to become Medicare-covered providers; part of the Department of Health and Human Services, CMS was called the Health Care Financing Administration (HCFA) before 2001.
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| Certificate of Mailing | A receipt purchased at the time of mailing that documents the date the material was presented for mailing to the U.S. Postal Service.
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| certification | An essential minimum standard of competence in a particular medical specialty, awarded by The American Board of Specialties; achieved through academic in-hospital training and successful completion of a comprehensive examination.
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| certified mail | A service offered by the U.S. Postal Service whereby the Postal Service keeps a record of delivery and the sender receives a mailing receipt.
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| CHAMPVA | Acronym for The Civilian Health and Medical Program of the Veteran's Administration; the government health insurance program that covers the medical expenses of families of veterans with total, permanent, service-connected disabilities; covers spouses and dependents of veterans who die as a result of injuries sustained in the line of duty.
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| channel | The chosen method of transmitting the message.
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| charge/receipt slips | Records of the doctor's services to each patient and the charges, combined with a tear-off receipt for the patient.
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| check | A written order to a bank to pay a specific amount of money.
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| CHEDDAR | A system of documenting medical data in a patient's chart using seven sequential categories: chief complaint, history, exam, details of problem/complaint, drug data, assessment, and return visit or referral.
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| chief complaint (CC) | The reason for the patient's visit to seek the physician's advice.
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| chronological résumé | The traditional and most common résumé style, which lists information in reverse chronological order.
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| clean claim | A medical insurance claim that is free of errors and that can be adjudicated.
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| clearinghouse | A service bureau that collects electronic claims from many different medical practices and forwards the claims to the appropriate insurance carriers.
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| closed files | The records of those patients who have moved away from the area, died, or terminated their relationship with the physician.
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| cluster scheduling | A method that brings several patients in at the same time, such as on the hour, to be seen by the provider; also known as wave scheduling.
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| CMS-1500 claim form | A paper claim for physician services.
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| code linkage | The connection between the diagnostic and procedural information, examined by insurance carriers to evaluate the medical necessity of the reported charges.
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| coding | (1) The placing of a number, letter, color, or underscore beneath a word to indicate where a document should be filed; (2) the process of assigning codes to diagnoses and treatments based on standard code sets.
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| coinsurance | The percentage of each claim that the insured person must pay; the percentage to be paid by the carrier is usually stated first as in “a rate of 80–20.”
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| collection agency | A business whose purpose is to collect unpaid debts for the creditor; usually used once other methods of securing payment have failed.
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| collection at the time of service | The payment for services by patients at the time of the visit, by cash, check, or credit card where acceptable; the payment method required for insurance copayments.
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| collection ratio | A percentage used to show the effectiveness of collection practices; the higher the collection ratio, the better the collection practices.
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| Collect on Delivery (COD) | The U.S. Postal Service delivery service that collects postal and other fees from the recipient when the postal material is delivered.
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| color coding | The organization of files according to a system of colored file folders.
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| compliance | The act of adhering to legal rules and regulations as well as high ethical standards through practices and procedures within the medical practice, in all aspects of medical care.
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| confidentiality | The legal requirement that a patient's medical information be kept secret except in certain clearly defined instances.
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| contributory negligence | The failure of a patient to follow the advice and/or instructions of the physician, thus contributing to neglect or an outcome that may not be satisfactory.
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| coordination of benefits (COB) | The clause in insurance policies which states that the insured who has two insurance policies may have only a maximum of 100 percent of the health costs.
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| copayment (copay) | The set charge, required by HMOs and some other insurers, to be paid by patients every time they visit the physician's office.
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| cover/application letter | A letter that introduces the applicant to the employer by supplying relevant information about the applicant as it relates to the available position.
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| CPT | The initials used for Current Procedural Terminology, a book published by the American Medical Association and updated annually; contains the most commonly used system of procedure codes.
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| cross-reference sheet | The indication, made on a sheet of paper or card, of other files where a copy of a particular document may be found.
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| customary fee | A physician's charge for a procedure or service determined by what physicians with similar training and experience in a certain geographic area typically charge.
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| cuts | Positions of tabs on folders.
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| cycle billing | A method of billing patients designed to stabilize cash flow and workload; involves dividing patients into groups of a size roughly equal to the number of times that billing will take place during the month.
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| daily journal | A record of services rendered by the physician, daily fees charged, and payments received; also called “general journal” or “daily earnings record.”
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| database | The complete history of a patient as contained in a problem-oriented medical record (POMR): includes the problem, medical, social, and family histories, a review of systems, and the physician's conclusions; also, any collection of related data, sets, or subsets of information.
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| database management application | A software program that helps the user enter data and sort the data into useful subsets of information.
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| dead storage | An area reserved for records that have been closed or that must be stored permanently; usually physically separate from where active files are kept.
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| decoding | The application of meaning by the receiver of a transmitted message.
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| deductible | A certain amount of medical expense the insured must incur before the insurance carrier will begin paying benefits.
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| deductions | The amounts of money withheld from earnings to cover required taxes, insurance, and so on.
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| Defense Enrollment Eligibility Reporting System (DEERS) | The system used to list individuals covered through TRICARE.
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| defensive medicine | Those practices of the physician designed to help him or her avoid incurring lawsuits, such as ordering additional tests to confirm a diagnosis, as well as follow-up visits.
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| delegative/laissez faire | A leadership style that uses a “handsoff” policy and tends to allow other office team members to make their own decisions.
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| Delivery Confirmation | The U.S. Postal Service delivery service that provides the date and time of delivery or attempted delivery.
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| dependability | The ability to complete work on schedule, do required tasks without complaint, and always communicate willingness to help; closely related to accuracy and thoroughness.
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| dependent | A person related to a policyholder, such as a spouse or child.
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| deposition | A sworn statement to the court before any trial begins and usually made outside of court.
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| deposits | Checks or cash put into a bank account.
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| diagnosis (Dx) | A term used interchangeably with “assessment” or “impression”; gives a name to the condition from which the patient is suffering.
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| diagnosis-related groups (DRGs) | A system used by Medicare to establish payment for hospital stays; based on groupings of diagnostic codes that show the relative value of medical resources used throughout the nation for patients with similar conditions.
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| direct earnings | Salaries paid to employees; see also indirect earnings.
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| disability insurance | A plan that provides reimbursement for income lost when the insured person is unable to work because of illness or injury.
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| double-booking appointments | The practice used, when the schedule is full, of entering overflow patient appointments in a second column beside regular appointments; in some cases, triple columns are used.
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| durable power of attorney | A legal document giving a stated person the legal right to make decisions for another. This can be for medical decisions, financial decisions, or both.
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| editing | The assessment of a document to determine its clarity, consistency, and overall effectiveness.
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| efficiency | The ability to use time and other resources to avoid waste and unnecessary effort.
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| EFT | The automatic withdrawal of employees' net pay from the practice account and the deposit to each employee's account; arranged for with the bank by the physician.
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| electronic claims | Claims that are completed and transmitted to insurance companies by computer, with the assembling of data and completion of claims done using medical billing software.
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| electronic health records (EHRs) | Healthcare databases compiled over the course of different patient encounters.
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| electronic mail service | A service offered by the U.S. Postal Service allowing the secure transmission of documents over the Internet.
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| e-mail | A telecommunications system for exchanging written messages through a computer network; also known as electronic mail.
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| emergency | A medical status in which the delay of care of a serious injury or illness would threaten the patient's life or body part.
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| empathy | Sensitivity to the feelings and situations of others that allows one to mentally put oneself in the other person's situation.
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| employer identification number (EIN) | A tax identification number that employers are required to have by the Internal Revenue Service (IRS).
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| encoding | Using words and gestures to convey a message.
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| endnotes | References that the author may have used as background or relevant information, placed on a separate page following the text of the manuscript.
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| EOB | The report sent to the patient and the healthcare provider by the insurance carrier informing them of the final reimbursement determination, explaining the decision, and appending reimbursement due the provider; used for paper claims.
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| ERA | The report sent to the patient and healthcare provider by the insurance carrier informing them of the final reimbursement determination, and containing the same additional information as the EOB; used for electronic claims.
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| ergonomics | The science of designing the work environment to meet the needs of the human body, while reducing the risks of injury or hazards without decreasing output.
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| established patient (EP) | A patient who has seen the physician or a physician of the same specialty within the same practice group for three or more years.
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| e-signature | A unique identifier created for each person through computer code; has the same legal standing as a printed signature.
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| ethics | The standards of conduct that grow out of one's understanding of right and wrong.
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| ethnocentrism | The tendency to believe that one's own race or ethnic group is the most important and that some or all aspects of its culture are superior to those of other groups.
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| etiquette | Those behaviors and customs that are standards for what is considered good manners.
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| express consent | The patient's approval, which may be given either orally or in writing; required for procedures that are not part of routine care.
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| Express Mail | Service offered by the U.S. Postal Service that provides next day delivery of items.
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| family history (FH) | Facts about the health of the patient's parents, siblings, and other blood relatives that might be significant to the patient's condition.
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| fee adjustment | The reduction of a fee based on the physician's decision of the patient's need; see also write off .
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| feedback | A receiver's response(s) to a message.
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| fee-for-service | A payment method through an insurance carrier whereby the patient (policyholder) pays for medical services at the time of receiving them and is reimbursed by the insurance company once it has reviewed and approved a claim describing the services; alternately, the policyholder's directive that the carrier pay the service provider directly once services are received.
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| fee schedule | A list maintained by each physician or medical practice of the usual procedures the office performs and the corresponding charges.
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| FICA | The law that governs the Social Security system and requires that a certain amount of money be withheld for Social Security benefits; employer pays half the amount withdrawn and employee pays the other half.
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| file server | A central computer within a computer network, used to store the computer programs and data that must be shared by all the computers in the network; also called, simply, a “server.”
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| first-class mail | The classification of mail weighing 13 ounces or less, which includes all correspondence, whether handwritten or typewritten, such as bills and statements of account, and is sealed against postal inspection.
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| first draft | The first complete keying of a manuscript.
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| fixed office hours | Designated hours during which the doctor is available for appointments; patients sign in with the receptionist and are seen in the order in which they arrive and sign in.
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| flexibility | Adaptability to new or changing requirements.
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| folders | Containers used to hold those items that are to be filed; frequently made of a sturdy material to withstand handling.
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| footnotes | Notes, usually at the bottom of a page, used to cite sources of information or quotations used in the text.
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| fraud | An intentionally dishonest practice that deprives others of their rights, such as falsifying credentials or submitting false or duplicate insurance claims.
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| full endorsement | The signature on a check indicating the person, account number, or bank to which the check is being transferred, and the payee's name.
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| functional résumé | The résumé format in which skills and accomplishments are organized into data groups that directly support the position goal.
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| FUTA | The federal law that requires employers to pay a percentage of each employee's salary; the amount paid provides a fund for employees once they are unemployed and seeking new jobs.
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| good judgment | The ability to use knowledge, experience, and logic to assess all aspects of a situation in order to reach a sound decision.
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| Good Samaritan Act | A law designed to protect a physician who provides emergency care from liabilities for civil damages that may arise from the circumstances.
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| graphics application | A software program that allows the user to manipulate images and to create original images electronically.
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| guarantor | The insurance policyholder for a patient.
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| guide | A rigid divider placed at the end of a section of files to indicate where a new section or category of files begins.
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| hard drive | A nonremovable disk built into the computer that serves as the computer's central “filing cabinet.”
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| HCFA-1500 | See CMS-1500 claim form.
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| HCPCS | Pronounced “hic-pics”; stands for Health Care Financing Administration's Common Procedure Coding System, for use in coding services for Medicare patients.
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| Health Insurance Portability and Accountability Act (HIPAA) | The federal law that protects the security and privacy of health information by regulating how electronic patient information is stored and shared.
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| hidden job markets | Employment markets that are less obvious and require more initiative by the job seekers to access.
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| history of present illness (HPI) | Information taken from the patient about symptoms: when they began, what factors affect them, what the patient thinks is the cause, remedies tried, and any past treatment for the symptoms.
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| HMO (health maintenance organization) | The oldest form of managed care; a medical center or designated group of physicians provides medical services to insured persons for a monthly or annual premium.
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| honesty | Truth telling, expressed in words and actions; a quality that enables the person to be trusted at all times and in all situations.
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| hospital insurance | Provides protection against the cost of hospital care and generally provides a room allowance for a maximum number of days per year; provisions exist for operating room charges, x-rays, lab work, drugs, and other necessary items during the patient's hospital stay.
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| IAAP | A worldwide organization that sponsors continuing education and a certification examination with the successful completion earning the designation of Certified Professional Secretary (CPS); also works with employers to promote excellence; formerly known as Professional Secretaries International (PSI).
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| ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) | A list of codes for diseases and conditions required for use in government healthcare programs and generally adopted by the healthcare profession.
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| implied consent | The patient's agreement that is not stated outright but is shown by the patient's having gone to the doctor's office for treatment.
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| impression | A term used interchangeably with “assessment” or “diagnosis”; gives a name to the condition from which the patient is suffering.
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| inactive files | The records of those patients who have not seen the doctor for six months or longer.
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| income statement | A financial statement showing profit and loss for a stated period of time, such as a quarter or a year.
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| indemnity plan | An insurance plan that provides a percentage of payment to the physician on a fee-for-service basis; the patient assumes responsibility for the remaining portion of the cost.
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| indexing | The process of selecting the name, title, or classification under which a document or an item will be filed.
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| indirect earnings | Amounts of money other than salary supplied to the employee, such as paid leave; also benefits such as employer-paid benefit programs that are worth amounts of money.
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| informed consent | The ability of the patient to make a sound decision to agree because the problem has been explained in clear language and the physician has given both treatment options and a prognosis.
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| initiative | The exercise of one's power to act independently.
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| input | Data and instructions from a computer user, provided to the computer through input devices, the most common of which is the keyboard.
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| inspecting documents | The act of checking each item received for filing to be sure that the information is complete and that the item is in good physical condition.
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| insured | May be the person who takes out an insurance policy and is responsible for the payments; may also refer to anyone, such as a spouse or dependent, covered by an insurance policy.
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| insured mail | Articles sent through the U.S. Postal Service or other carriers that are covered against loss or damage through the purchase or provision of insurance.
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| interest | Money paid by the bank to depositors in return for the use of the depositor's money.
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| Internet | A vast, worldwide computer network that links millions of computers; enables almost instantaneous sharing of information in various digital forms—text, graphics, sound, video, and so on.
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| itinerary | A daily schedule of events for a traveler, containing such information as flight numbers and times and hotel and car arrangements.
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| keywords | Words used throughout the résumé that directly relate to the position requirements.
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| label | An oblong piece of paper, frequently adhesive, used to identify a file by title or subject.
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| laptop | A portable computer, designed to fit into a briefcase; able to run on either plug-in current or batteries.
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| lateral files | Drawers or shelves that open horizontally where files are arranged sideways from left to right instead of from front to back.
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| liability | Legal responsibility.
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| licensure | The act of the state whereby healthcare providers, and those in other professions, are granted licenses to practice under certain conditions, including meeting the requirements of education and training.
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| litigation | The bringing of lawsuits against an individual or other entity.
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| living will | A written document providing directions for medical care to be given if a competent adult becomes incapacitated or otherwise unable to make decisions personally; also know as an advance directive.
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| mainframe | A computer designed to store massive databases that many users may all access at the same time.
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| major medical insurance | A policy that offers protection from large medical expenses.
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| malpractice | An act that a reasonable and prudent physician would not do, or the failure to do some act that such a physician would do.
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| managed care | A system that combines the financing and delivery of healthcare services to members.
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| management qualifications | Usually regarded, for the administrative medical assistant, as the ability to be a team player; the ability to do strategic planning; and the ability to increase productivity.
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| maturity | Emotional and psychological integrity composed of many qualities and skills.
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| Media Mail | The rate used by the U.S. Postal Service for the mailing of books, videotapes, looseleaf pages, and binders; also called “Book Rate.”
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| Medicaid | A health benefit program, jointly funded by federal and state governments, designed for people with low incomes who cannot afford medical care.
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| medical insurance | Insurance that covers benefits for outpatient medical care.
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| medical practice acts | The laws of each state governing who must be licensed to give care, the rules for obtaining licensure, the grounds for revoking licenses, and the reports required by state law.
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| Medicare | The federal health plan that provides insurance to citizens and permanent United States residents 65 years and older, people with disabilities (including kidney failure), and dependent widows; divided into Part A, hospitalization insurance, and Part B, medical insurance.
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| medicolegal | A type of document that provides evidence of patient care and is considered a legal document in a court of law.
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| meeting minutes | Official record of a meeting, including the major pieces of business conducted; the names and contributions of any attendees who spoke; the date, place, and time of the meeting; those present and absent; and the duration of the meeting.
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| Message | ideas formulated by the sender to be received by the recipient.
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| micrographics | The process of storing records in miniaturized images, usually in a microfiche sheet or ultrafiche format, viewed on readers that enlarge the image.
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| minicomputer | A computer having less power than a mainframe; may operate for a single user or along with many terminals.
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| mobile-aisle files | Open-shelf files that are moved manually or by motor.
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| modem | A computer component that allows computers to communicate through telephone lines.
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| modified-block-style letter | The arrangement of a letter whereby the date line, complimentary closing, and signature all begin at the center of the page and all other lines begin at the left margin.
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| monitor | The display screen attached to the computer that shows to the user the results of commands, instructions to the computer, and data input.
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| monthly billing | The system of sending each patient an updated statement of payments made and charges owed to the physician once per month; these are all sent from the office at the same time every month.
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| monthly summary | The report that shows the daily charges and payments for the entire month.
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| networking | A means of communicating, exchanging information, and pooling resources among a group of electronically linked computers.
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| new patient (NP) | A patient who has not seen the physician or a physician of the same specialty within the same practice group for three or more years.
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| no shows | A patient who, without notifying the physician's office, fails to show up for an appointment.
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| noise | Internal and external interference with the communication process.
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| numeric filing | A system of document storage in which each patient is assigned a number; see also accession book.
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| objective | The physician's examination of the patient contained in the SOAP record; results of the examination may be shown under the heading “Physical Examination (PE).”
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| OCR | Optical character reader equipment used to scan materials for data, such as a ZIP code.
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| online | Connected to a computer network for purposes of communicating, gathering, or exchanging information.
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| open office hours | A method of seeing patients during hours when the physician is available and no appointment is made, such as from 10 a.m. to noon; patients are seen on a first-comefirst- seen basis.
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| open-shelf files | Shelves that hold files, may be adjustable or fixed, and may extend from floor to ceiling; shelves accept files placed sideways with identifying tabs protruding.
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| operating system | The internal programming that tells the computer how to use its own components by controlling the basic functions of the computer and directing the computer to interact with the user and with input and output devices.
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| out guide | A card placed as a substitute for a file folder; indicates that a file has been removed.
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| output | Processed data sent back to the user by the computer through output devices, such as a monitor.
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| output device | A device used to display electronic data.
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| outside services file | A list of professional and other resources kept in either a paper or electronic format.
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| palm computer | A version of the personal computer small enough to be held in the palm of the hand; less powerful than other personal computers but usually has e-mail, fax, and other features; also called “palmtop” or, technically, “personal digital assistant (PDA).”
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| participating (PAR) provider | A physician who joins an insurance plan and agrees to provide services according to the rules and payment schedules of the insurance plan.
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| parcel post | The classification of mail for items 70 pounds or less and no more than 130 inches in length and girth; mailing fee is based on weight, distance to travel, and shape.
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| participative/democratic | A leadership style in which the leader offers advice but also participates in the team dynamics and seeks input from other team members.
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| password | A code assigned to a computer user as a security measure; limits access to computer files and safeguards information.
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| past medical history (PMH) | A listing of any illnesses the patient has had in the past; includes treatments and procedures performed.
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| patient education materials | Printed materials provided to patients to give information on caring for their health, lists of resources, descriptions of frequently requested tests and procedures, and the like.
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| patient encounter form | The list made of procedures, diagnoses, and charges during any particular patient visit.
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| patient information brochure | A booklet that provides vital information about the practice, such as services offered; qualifications of the physicians; instructions for making appointments; and ordering refills of prescriptions.
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| patient information form | A form used to collect a patient's personal and insurance information; usually updated at least every 12 months.
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| patient statement | The copy provided to the patient of all charges incurred by the patient and all payments made by the patient or the patient's insurance company; also called the “patient bill.”
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| payroll | The total earnings of all the employees in the practice.
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| perfectionism | setting unrealistic expectations and goals and being dissatisfied with anything less.
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| personal computer | A computer designed for one user; may reside on a desktop or may be portable, as laptop and notebook computers are; referred to as “PCs” or, less frequently, as “microcomputers.”
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| personal reference | An individual who knows a job seeker's personal ethics, honesty, and trustworthiness.
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| petty cash fund | A fund containing small amounts of cash used for expenses so minor that checks would not be written to pay them: postage stamps, cab fares, and the like.
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| physical exam (PE) | A complete examination of the patient in which findings for each of the major areas of the body are stated or an examination that covers only the body systems pertinent to that particular visit.
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| plan | The treatment, as stated in the SOAP record, listing prescribed medication, instructions given to the patient, and recommendation for surgery or hospitalization.
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| plain text résumés | résumés with simplified formatting; used to submit an online résumé.
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| policies and procedures manual | An employee handbook that contains job descriptions, job responsibilities, instructions for completing routine tasks, personnel policies, and so on.
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| Postnet | A bar code interpretation of the ZIP code or the ZIP+4 consisting of a series of long and short vertical lines which is placed on the lower portion of the mailing address.
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| posting | The activity of transferring an amount from one record to another.
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| power words | Action verbs used to showcase your skills.
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| PPO (preferred provider organization) | A popular type of managed care plan that contracts to perform services for members at specified rates, usually lower than fees charged to regular patients; also provides members with a list of healthcare providers from which to receive services at lower PPO rates.
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| practice analysis report | The report used to analyze the revenue of the practice during any specified length of time; contains lab charges, patient payments, copayments, adjustments, and so on.
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| preauthorization | The requirement by HMOs and some other insurance plans that the physician obtain permission from the insurance plan before delivering certain types of services.
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| premium | The rate charged to a person who holds an insurance policy; usually paid on a regular basis, monthly or quarterly.
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| primary care provider (PCP) | The physician who coordinates the patient's overall care and ensures that various medical services are necessary; described as a “gatekeeper” and is often an internist or a general practitioner.
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| printer | A computer output device that produces a hardcopy of electronic information or images.
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| Priority | Mail A service offered by the U.S. Postal Service; two-day delivery service within most domestic destinations.
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| problem-oriented medical record (POMR) | A patient record organized around a list of the patient's complaints or problems; contains a database of the patient's history, initial plan, and problem list.
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| problem-solving | The ability to find solutions through flexibility, advice seeking, information gathering, and good judgment.
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| procedure day sheet | A numeric listing of all the procedures performed on a given day; includes patient names, document numbers, and places of service; may be a computerized journal form.
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| professional image | The appearance, manner, and bearing that reflect health, cleanliness, and wholesomeness; shown by evidence of healthful habits, good grooming, and appropriate dress.
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| professional reference | An individual who knows a job seeker's work ethics and skills.
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| proofreading | The careful reading and examination of a document for the sole purpose of finding and correcting errors.
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| provider | A physician or other healthcare professional.
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| punctuality | The ability to be on time.
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| reasonable fee | A charge for the physician's service that is a usual and stated charge and/or the charge by physicians in the geographic area with similar experience.
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| records management | The systematic control of the steps in the life of a record, from its creation through its maintenance to its disposition.
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| Red | Flag Requirements Mandated federal regulations that must be implemented by creditors to protect covered financial accounts from identity theft.
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| referral | The recommendation from the primary care provider (PCP) that the patient use a specialist for a specific service; in the referral document, the PCP names the provider and states the service.
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| registered mail | Items sent through the U.S. Postal Service for which a delivery record is maintained at the mailing post office; receipt is given to the sender at the time of mailing.
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| registration | A permit granted to a physician for prescribing and dispensing pharmaceutical medications.
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| relative value scale (RVS) | The assignment of values to medical services based on an analysis of the skill and time required to provide them; values are multiplied by a dollar conversion factor to calculate fees.
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| release of information | Written permission signed by the patient, authorizing the proper transfer of information to those who have made a legitimate request or have a legitimate need; often called simply a “release.”
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| releasing | The indication, by initial or by some other agreed–upon mark, that a document has been inspected and acted upon and is ready for filing.
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| reprints | Copies of an already published article; available from the publisher for a small fee or free when the physician is the author.
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| resource-based relative value scale | The payment system used by Medicare; establishes relative value units for services based on what each service costs to provide.
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| Restricted Delivery | Direct delivery through the U.S. Postal Service; item delivered only to the addressee or addressee's authorized agent.
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| restrictive endorsement | Signing, or endorsing, of a check by writing, or stamping “For Deposit Only,” the account number to which the check should be deposited, and the signature.
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| retention | The length of time that records are kept; regulated in many cases by state law; also regulated by Medicare regulations.
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| return receipt | A piece of paper provided by the U.S. Postal Service to give the sender proof of delivery.
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| review of systems (ROS) | The physician's specific questions to the patient about each of the body's systems.
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| ROM (read-only memory) | The permanent memory of the computer.
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| rotary circular file | A small desktop file designed to rotate, thus permitting the use of both sides of an index card.
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| rule out (R/O) | A possible diagnosis that must be proved or “ruled out” by further tests.
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| scannable résumé | A format style used for résumés read by optical character readers.
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| scanner | A computer input device that takes a picture of a printed page or graphic and copies it into the computer's memory.
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| screening calls | The practice of evaluating calls to decide on appropriate appointment action.
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| scrubber program | Software used to detect and correct medical insurance claims prior to being submitted to the insurance carrier.
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| self-motivation | The quality expressed by willingness to contribute without being asked or required to undertake a task.
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| settlement | An agreement by parties on opposing sides; may be the result of a court decision or an agreement arrived at without trial; may involve compensation to the complaining party.
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| simplified-style letter | The arrangement of a letter in such a way that all lines begin at the left margin, a subject line substitutes for the salutation, and the complimentary closing is eliminated; open punctuation is used and the writer's name is in all capital letters on one line.
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| Signature Confirmation of Delivery | U. S. Postal Service delivery service that provides the date, ZIP, time of delivery (or attempt), and signature of the person who accepted the delivery.
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| SOAP | An acronym used to refer to the most common system for outlining and structuring notes on a patient's chart; the acronym stands for the headings used: Subjective, Objective, Assessment, and Plan.
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| social history (SH) | Information that may be pertinent to treatment regarding the patient's marital history, occupation, interests, and eating, drinking, and smoking habits.
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| sorting | The arrangement of documents in the order in which they will be filed.
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| sponspor | The TRICARE and CHAMPVA term for enlisted military personnel through whom medical coverage is provided.
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| spreadsheet programs | Software used for financial planning and budgeting.
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| standard punctuation | The placing of a colon after the salutation of a letter and the placing of a comma after the complimentary closing.
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| statute of limitations | A law made by each state government setting a time limit beyond which the collection of a debt, or the prosecution of many kinds of crimes, is not subject to legal action; varies from three to eight years.
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| statutory reports | Information of a confidential nature that is required by law to be filed with state departments of health or social services.
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| storing | The placement of an item in its correct place in a file; also called “filing.”
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| stress | Emotional and/or physiological reactions to external motivators.
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| subject filing | A system of document storing whereby the placement of related material is alphabetic by subject categories.
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| subjective | The patient's description of the problem or complaint, including symptoms, when symptoms began, associated factors, remedies tried, and past medical history.
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| subpoena | A legal document ordering that all materials related to a lawsuit be delivered to court; also, a legal document requiring people to divulge information.
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| subpoena duces tecum | A legal order for a person to appear, testify, and present specified documents.
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| summons | A written notice to the person being sued (defendant), ordering the person to answer charges presented in the document.
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| supercomputer | The most powerful computers available.
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| surgical insurance | Provides protection for the cost of the surgeon's fee for performing surgery; generally includes coverage for the cost of anesthesia.
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| tab | A projection that extends beyond the rest of the file folder so that the folder may be labeled and easily viewed.
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| tact | The ability to speak and act considerately, especially in difficult situations.
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| team player | One who is generous with his of her time, helping other staff members when necessary; who observes both the written and unwritten rules of the office; and who practices professional and personal courtesy.
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| telephone etiquette | A set of skills and attitudes used when answering the phone that allows the assistant to sound alert, interested, and concerned.
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| template | A standard electronic version of a frequently used document; may be altered slightly from one use to the next; saves user time in keying and formatting commonly used documents and forms.
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| terminated account | The account of a patient from whom it has not been possible to extract payment; also the status of accounts at the end of the patient-physician relationship for other reasons.
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| third-party liability | The assumption of responsibility for charges related to a patient by someone other than the patient—for example, children of aged parents.
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| third-party payer | An insurance company that agrees to carry the risk of paying for medical services for the insured.
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| thoroughness | The ability to perform tasks with attention to completeness, correctness, and detail.
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| title page | The first manuscript page, which contains the title of the manuscript and the author's name, degree and/or title, and affiliation.
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| transcription | A method of recording data whereby the medical provider dictates data into a recording device and an individual trained in medical keyboarding skills keys the information into documentation format.
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| travel agent | A professional, often certified by the travel industry, who may work independently or within a travel company; handles all aspects of travel arrangements at no charge to the customer.
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| triage | The determination of how soon a patient needs to be seen by the physician based on whether the patient's condition requires immediate attention.
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| TRICARE | The Department of Defense health insurance plan for military personnel and their families; coverage extends to active or retired members of the U.S. Army, Navy, Marines, Air Force, Coast Guard, Public Health Service, and National Oceanic and Atmospheric Administration, and dependents of military personnel killed on active duty; formerly called CHAMPUS.
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| urgent | A medical injury or illness, though not life threatening, that needs prompt medical attention within a 24-hour time period in order to prevent serious decline of the patient's condition
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| usual fee | A healthcare provider's average charge for a certain procedure or service, usually shown on the physician's fee schedule.
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| vertical files | Drawer files, contained in cabinets of various sizes; files are arranged from front to back.
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| visible job markets | Employment markets composed of resources that are traditional and most obvious.
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| virus | A malicious computer program written with the intent of harming other data, software, and/or computers.
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| voice recognition technology | A program used along with a word processing application to transcribe spoken words into text without the use of a keyboard.
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| wave scheduling | Fixed office hours combined with scheduled office appointments for a specific number of patients.
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| wireless communication | The use of radio waves rather than wires or cables to transmit data through a computer network.
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| word processing program | Software used to enter, edit, format, and print documents.
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| work ethic | The collective habits and skills that help the worker deal effectively with work tasks and with people.
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| workers' compensation | State law and insurance plan requiring employers to obtain insurance in case of employee accident or injury.
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| write-off | The subtraction of an amount from a patient's bill; entered into the patient ledger as an adjustment.
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| ZIP | abbreviation for Zone Improvement Plan which is a system of the U.S. Postal Service of designating delivery of mail based on numerical codes.
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| ZIP+4 | an extension of the postal ZIP system that adds an additional four codes which represent a geographic segment such as a building number to the original ZIP code.
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| Zip drive | A small disk drive that may be installed inside a PC or operated externally; stores large files or creates archives of files for long-term storage.
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