Administrative and Clinical Procedures for the Canadian Health Professional PDF

To the memory of my son Spencer, who passed away on April 23, 2017. Also to all of the frontline workers for their perseverance and commitment to patient care during the COVID-19 pandemic. Brief Contents Part I  Introduction  1 Chapter 11 The Billing P...

To the memory of my son Spencer, who passed away on April 23, 2017. Also to all of the frontline workers for their perseverance and commitment to patient care during the COVID-19 pandemic. Brief Contents Part I  Introduction  1 Chapter 11 The Billing Process   326 Chapter 1 The Administrative Health Professional Chapter 12 Claims Submission  360 (AHP) 2 Chapter 13 Health Information Management   388 Part II  Health in Context  41 Part V  Hospital Procedures  423 Chapter 2 Health and the Individual   42 Chapter 14 The Hospital Setting   424 Chapter 3 Culture and Health   66 Chapter 15 Hospital Documents and Procedures   466 Chapter 4 The Canadian Health Care System   90 Chapter 16 Doctor’s Orders: Procedures and Process  506 Part III  Health Care Basics  113 Chapter 5 Standards and Safety in Health Part VI   Understanding and Applying Care  114 Administrative Tasks and Chapter 6 Diagnostic Tests  148 Responsibilities  535 Chapter 7 Pharmacology  181 Chapter 17 Intravenous Therapy  536 Chapter 18 Patient Nutrition  556 Part IV   Health Office Chapter 19 Digestion and Excretion   572 Procedures  213 Chapter 20 The Cardiorespiratory Systems   587 Chapter 8 Communication in the Health Chapter 21 Rest and Activity   604 Office  214 Chapter 9 Patient Registration and Scheduling Glossary  614 Appointments  260 Index  621 Chapter 10 Health Care Plans   299 Credits  640 vii Contents Preface    xvii Mental Health and Addiction   49 Leading Causes of Mortality and Morbidity Part I  Introduction   1 in Canada  51 Behavioural Responses to Illness   52 1 The Administrative Health Professional The Health–Wellness Continuum   53 (AHP)  2 The Stages of Illness Response   54 Employment Opportunities and Related Job Titles   3 1. Preliminary Phase   54 What’s in a Name?   3 2. Acknowledgement Phase   54 Client versus Patient   3 3. Action Phase   55 Administrative Health Professional in Primary 4. Transitional Phase   55 Care Settings  4 5. Resolution Phase   55 Employment Opportunities  5 Implications for the Health Office Occupational Settings  6 Professional  56 Necessary Attributes and Skills of the Administrative Sick Role Behaviour   56 Effects on Others   57 Health Professional  9 Implications for the Administrative Health Attributes  10 Professional  58 Skills  15 Illness and Personality Types   58 Ethical Principles in Health Care Settings   17 The Effects of Hospitalization   59 Ethical Theories  17 Privacy  60 Ethical Principles  18 Autonomy  60 Ethical Decision Making   20 Lifestyle  61 Duties and Responsibilities   20 Role Function  61 Administrative Responsibilities  21 Financial Security  61 Clinical Responsibilities  22 Implications for the Administrative Health Entering the Workplace   23 Professional  61 The Workplace Environment   23 Health Status  61 Job Prospects  25 Salaries and Benefits   25 3 Culture and Health   66 Résumés  26 Immigration Policies and Settlement Patterns   67 Job Search  27 What Is Culture?   68 Professional Growth  29 Ethnicity  69 Professional Associations  29 Cultural Diversity, Prejudice, and Ethnocentrism   71 Workplace Experience  30 Cultural Diversity  71 Continuing Education  31 Prejudice and Ethnocentrism   72 Simulated Office Experience   31 Cultural Competence and Cultural Understanding   73 Cooperative Work Experience   32 The Need for Intercultural Understanding   74 Volunteer Work  33 Appendix 1A: Sample Résumé   38 Barriers to Cross-Cultural Health Care   77 Appendix 1B: Job Descriptions   39 Health Care Delivery   77 The Hospital Environment   78 Professionals’ Attitudes and Lack Part II  Health in Context  41 of Knowledge  79 Differences in Beliefs and Practices   79 2 Health and the Individual   42 Confidentiality  79 Health Beliefs  43 The Philosophy of Prevention   80 Health Behaviour  44 The Concept of Illness and Treatment   80 Concepts of Health and Wellness   45 Explanatory Systems  80 Health  45 Attitudes towards Mental Illness   81 Wellness  45 End-of-Life Issues  82 Current Issues in Health Care   48 Childcare  82 The Aging Population   48 Modesty  82 viii  Religious Constraints  83 Microorganisms  123 Number of Visitors   83 The Chain of Infection   124 Childbirth  83 Vaccines  126 Language Difficulties  84 Infectious Diseases of Particular Concern   129 Using an Interpreter   85 Preventing the Spread of Infection   130 Medical Asepsis  130 4 The Canadian Health Care System   90 Surgical Asepsis  134 Historical Chronology of Health Care in Canada   90 Sanitizing, Disinfecting, and Sterilizing   134 The Canada Health Act   92 Standard Precautions  137 Principles  92 Gloves  138 Conditions  93 Mask, Eye Protection, and Face Shield   140 Gowns or Aprons   140 Responsibilities and Financing   93 Equipment Used for Patient Care   140 Federal Government Responsibilities   93 Linen  141 Provincial and Territorial Responsibilities   94 The Health Environment   141 Financing  94 Assisting with Examinations/Procedures   141 Payment of Premiums   95 Health Care Delivery   95 Preventing Injury in the Health Office   142 Personal Risk Factors   142 Primary Health Care   96 Environmental Risk Factors   144 Specialists and Primary Care   96 Providing a Safe Environment   144 Primary Health Care Settings in Canada   97 Personal Safety Equipment   144 Primary Care Delivery in Canada   100 The Particulars of Patient Enrollment Models   100 6 Diagnostic Tests  148 Advantages of Primary Care Models   101 The Role of Diagnostic Tests in Patient Care   149 Implications for the Administrative Health Diagnostic Tests and Patient Education   150 Professional  102 Diagnostic Facilities and Related Health Payment Options for Physicians   103 Professionals  151 Fee-for-Service  103 Allied Health Professionals   152 Shadow Billing  104 Physician Working in Laboratory and Diagnostic Remuneration Options for Opted-In/Opted-Out Facilities  153 Physicians  104 Laboratory and Diagnostic Tests: An Overview   153 Direct Billing  104 The Life Cycle of a Diagnostic Test   154 Extra-Billing and User Fees   104 Salaries  105 Clinical Laboratory Tests   157 Global Budget  105 Hematology  157 Sessional Payment  105 Blood Bank/Blood Transfusion   160 Capitation  105 Bio-chemistry  161 Indirect Capitation  106 Urinalysis  164 Blended Payment  106 Microbiology  167 Fees for Uninsured Services   106 Diagnostic Imaging  169 Providers Eligible to Bill Fee-for-Service   107 X-Ray  169 Other Providers  108 Endoscopic Retrograde Cholangiopancreatography Finding a Family Doctor   109 (ERCP)  170 Cholecystography  170 Barium Enema  171 Part III  Health Care Basics  113 Barium Swallow  171 Ultrasonography  171 5 Standards and Safety in Health Care   114 Proton Emission Tomography (PET)   172 Quality Assurance in Health Care   115 CT or CAT Scanning   172 Hospitals  115 Magnetic Resonance Imaging (MRI)   172 Health Offices  115 Mammography  173 The Incident Report   116 Bone Mineral Density Test   173 Occupational Health and Safety   117 Tests for the Gastrointestinal System   173 Workers’ Compensation  118 Tests for the Cardiovascular System   175 Infection Prevention and Control: How Infections Spread   118 Preparing and Handling Specimens   176 The COVID-19 Pandemic   119 Urine specimens  177 Classification and Patterns of Infection   122 Receiving Test Results   177 Contents ix 7 Pharmacology  181 Effective Telephone Communication   225 Pharmacology and Related Health Professionals   182 Improving Your Telephone Manner   226 The Pharmacist  183 Taking Calls  226 The AHP and Pharmacology   184 Answering the Phone   227 Drug sources and names   185 Handling Incoming Calls   228 Drug Sources  185 Handling Typical Calls   229 Drug Names  186 Calls from the Hospital   233 Handling Outgoing Calls   238 Relevant Information about Frequently Used Communicating with Colleagues   239 Medications  188 Hypoglycemics (Type 2 Diabetes)   188 Communication Devices  241 Hypoglycemics (Type 1 Diabetes)   189 The Fax Machine   241 Antibiotics  190 Sending and Receiving Reports Using EMR Anticoagulants  191 Connectivity  242 Important Information  192 Telephone Devices and Messaging   244 Managing Telephone and Messaging Equipment   244 The Law and Dispensing Drugs   192 Telephone Answering Options   246 Routes by Which Drugs Are Administered   194 Mobile Phones  247 Topical/Transdermal Route  194 Email  248 Inhalation Route  195 Patient Portals  249 Otic Route  195 Written Communication  250 Ophthalmic Route  196 Using Macros  250 Nasal Route  196 Signs  251 Sublingual or Buccal Route   196 Incoming Mail and Packages   253 Vaginal Route  196 Outgoing Mail  255 Rectal Route  196 Ending a Doctor–Patient Relationship   256 Oral Route  196 Parenteral Route  197 9 Patient Registration and Scheduling Effects of Drugs   198 Appointments  260 Therapeutic Action  198 Patient Registration  261 Allergies to Drugs   199 Self-Registration  261 Other Factors That Influence a Drug’s Therapeutic Health Card Validation   262 Effect  200 Methods of Validation   263 Natural Health Products   201 Checking Patient Information   265 Interactions with Prescription Medications   202 Invalid Cards  266 Patient Education  202 Fraudulent Cards  266 The AHP and Prescriptions   203 A Note on Confidentiality   267 Repeats and Renewals   204 Scheduling Software  267 Phoned and Faxed Prescription Requests   206 Basic Features of Scheduling Software   267 Prescriptions and Drug Misuse   208 Day Sheet  271 Avoiding Drug Errors   209 Appointment Cards  273 Reminders  273 Part IV  Health Office Procedures  213 Confidentiality and Scheduling   273 Scheduling Procedures  274 8 Communication in the Health Office   214 Pre-editing the Provider’s Scheduler   274 Plain Language  215 Scheduling Templates  275 Why Plain Language?   215 Standard Terminology  275 Plain Language Tips   216 Scheduling considerations  275 Face-to-Face Communication  218 Types of Scheduling   277 Greeting the Patient   218 Stream or Fixed-Interval Scheduling   277 Addressing the Patient   219 Double Scheduling or Double-Column Booking   277 The Wait  220 Affinity and Modified Scheduling   278 Escorting Patients to the Examination Room   220 Scheduling Office Visits in a Pandemic and Post- When the Patient Is Leaving   221 pandemic Environment  279 Communication with Patients with Altered Mental Virtual Care  280 Health  221 Standard Times for Appointments   284 Interacting in Difficult Situations   221 Categories of Assessment   284 x Contents  Managing Disruptions to the Schedule   287 Physician Registration  333 Catch-Up Time  288 Specialty Codes  334 Cancellations  288 Understanding Medical Billing Codes   337 Patients Who Are Late   289 Diagnostic Codes  337 The Family Visit   289 Service/Visit Codes  337 Patients Who Refuse to See Team Members   291 Codes and Physical Examinations   340 Scheduling Variations  291 Other Codes  341 New Patients  292 Premium Codes  341 Appointments for Patients’ Forms   292 Diagnostic and Therapeutic Procedures   341 Appointments for Drug Representatives   292 Tray Fee  342 House Calls  293 Technical and Professional Components   343 Appointments with Specialists   293 Special Service Code Notifiers   343 Scheduling Patients for Surgery   294 Time Units  344 Other Applications for Premium Codes   344 10 Health Care Plans   299 Special Visit Premium Code/Call-Out Insured and Uninsured Services   300 Premiums  344 Insured Services  301 Hospital and Long-Term Care Visits and Uninsured Services  302 Assessments  345 Supplementary Services  304 Specialized Codes and Primary Care Groups   346 Home and Community and Home Care “Q” Codes Used in Ontario   347 Services  304 Billing Examples Illustrating the Inclusion Long-Term Care/Residential Care Facilities   304 of Q Codes   348 Drug Benefit Plans   305 Billing Examples  349 The Drug Benefit Formulary   306 Intermediate Assessment in the Office   349 Physiotherapy  306 Minor or Brief Assessment in the Office   350 Ambulance Services  306 Office Visit for a Procedure   350 Optometry  306 Premium Codes: Out-of-Office Visit   350 Travel Assistance  307 Forms Commonly Used in Claims Submissions   351 Determining the Value of an Insured Service   308 Reciprocal Claim Form   351 Complexity of the Assessment   308 Out-of-Province/Territory Claim Form   351 Time-Based Services  308 Request for Approval of Payment for a Proposed The Patient’s Age   309 Dental Procedure  354 Additional Interventions  309 Request for Approval for Proposed Surgery   354 Time, Location, and Special Circumstances   309 Request for Prior Approval for Out-of-Country Independent Consideration  309 Health Services  354 The Fee Schedule   309 Health Card Number Release Form   354 Health Cards: Eligibility and Management   310 Claims Monitoring and Control   354 Payment of Premiums   310 Prior Approval  356 Health Cards  310 Verification Letters/Service Verification Registering for Provincial or Territorial Health Audits  356 Insurance Coverage  312 Updating and Correcting Cards   317 12 Claims Submission  360 The 3-Month Waiting Period   320 Web-Based Claims Submission   361 Coverage outside Canada   320 Support  361 Coverage in Other Provinces   321 Security  361 Billing for Out-of-Province/Territory Patients   321 Capabilities of Electronic Transfer   362 Private Insurance  321 Electronic Transfer and Claims Deadlines   362 Motor Vehicle Insurance   322 Claims Submission: A Summary   363 Workers’ Compensation  323 Your Role in the Claims Submission Process   363 The Ministry  363 11 The Billing Process   326 Components Involved in Claims Submission   363 The Cycle of a Claim   327 Software Billing Options   363 Primary Care Patient Encounters   328 Information Components of a Claim   364 Medical Office or Clinic Encounters   328 Your Role in the Claims Submission Process   371 Consultation  328 Assigning Responsibilities  371 General Assessment/Complete Examination   330 Uploading Claims  372 Contents xi  Codes for Rejected Claims   372 Archiving  411 Explanatory Codes  372 Paper Charts  412 Error Codes (Ontario)   373 Electronic Health Information   412 Action Codes (Alberta)   373 Privacy, Security, and Confidentiality   413 Feedback from the Ministry   373 Charts in a Group Practice   413 File Reject Message   374 Transfer of Medical Information   413 Batch Edit Report   374 Mandatory Reporting  413 Claims Error Report   374 Minor Patients  414 Payment and Remittance Advice   375 Patient Access to Their Health Information   414 Computer-Generated Reports  377 Patient Portals  414 Payment of Claims   377 Charts from Hospitals   415 Billing for Services Not Publicly Insured   378 Privacy Legislation in Canada   415 Services Charged to the Patient   378 Provincial Health-Related Privacy Acts   418 Accepting Payment  379 Personal Information Defined   418 Insurance Coverage  380 Privacy by Design   420 Collection  380 Forms Management  420 Third-Party Services  380 13 Health Information Management   388 Part V  Hospital Procedures  423 Health Information: The Basics   389 14 The Hospital Setting   424 Health Information: What Is It?   389 Health Care Facilities in Canada   425 Health Information Specialists   389 Funding Mechanisms for Hospitals   425 The Canada Health Infoway   390 Third-Party Partnerships  425 The Health Record   390 Classification of Health Care Facilities   426 The Electronic Medical Record   391 General Hospitals  426 The Electronic Health Record   391 Convalescent Hospitals  426 Electronic Medical Records Systems   391 Chronic Care Facilities   426 Creating an EMR   392 Nursing Homes  427 Advantages of an Electronic Medical Record Psychiatric Hospitals  427 System  393 Drug Addiction/Alcoholic Treatment The Electronic Medical Health System   394 Centres  427 Learning a New Electronic Medical Record System: Hospice  427 What to Expect   394 Accreditation of Health Care Facilities   428 Data Entry in the Electronic Medical The Organizational Structure of a Hospital   429 Record  395 Home and Community Care   430 Security and the Electronic Medical Restructuring of Hospitals and Hospital Record  395 Services  431 Levels of Access to Electronic Medical Record Cost-Saving Initiatives within Hospitals   432 Systems  395 Hospital Departments and Services   432 Passwords  396 Hospital Departments  433 General Security Considerations   396 Patient-Care Unit  436 The Patient’s Chart   398 Surgical Patient-Care Units   437 Components of a Chart   398 Intensive Care Units   438 Life Cycle of a Record   405 Emergency Departments  438 Creation  405 Outpatient Clinics  438 Maintenance  406 Supportive Services  438 Provision  406 The Health Care Team   440 Disposition  407 Physicians  440 Computerized versus Traditional Systems in a Unit Manager or Clinical Leader   440 Doctor’s Office  408 The Clinical Resource Nurse   441 Filing Systems  408 Nurses  441 Identification Systems  408 Personal Support Workers   442 Centralized versus Decentralized Storage   410 Paramedics  442 Filing Paper Charts   410 Orderlies/Team Attendants  442 Filing Office Forms   411 Pharmacists  442 Computerized Record Keeping   411 Physiotherapists  443 xii Contents  Respiratory Therapists  443 Generating an electronic chart   479 Laboratory Technologists and Technicians   443 Old Charts  480 Registered Dieticians  443 Framework of an eChart   480 Housekeeping Staff   444 The Admission or Face Sheet   481 The Clinical Secretary   444 Admission Interview/Assessment Clerical/Secretarial Responsibilities  444 Documentation  483 Communication Responsibilities  446 The Surgical Chart   486 Cross-Coverage  447 The Surgical Unit: Your Responsibilities   489 Scope of Practice   447 Current Orders  489 Choosing Your Job Setting   447 Preoperative Preparation  489 Anatomy of a Patient-Care Unit   449 OR Schedules  489 The Nurses’ Station   449 Confidentiality, Security, and Patients’ The Treatment Room   451 Charts  490 The Clean Utility Room   451 Security on the Maternal–Child Unit   491 The Dirty/Soiled Utility Room   451 Transfer and Discharge Procedures   491 Medication Room and Medication Transfers within a Hospital   491 Management  452 Interhospital Transfers  492 Storage Room  452 Discharges  493 Conference/Communication Room  453 Unauthorized Departures  497 Kitchen  453 Death of a Patient   497 Computer/Dictation Room  453 Other Standard Files, Manuals, and Resources   500 Waiting/Reception Room  453 Requisitions  500 Patient Teaching/Education Room   454 Patient Referral and Community Agency Housekeeping Supply Room   454 Forms  500 Dumbwaiter  454 Teaching Material  500 Communication Devices  454 Daily Assignment Schedule   501 Telephones  454 Transportation Services Records   501 Paging Systems  455 The Hospital Intranet   501 Mobile Devices and Wireless Devices in the Isolation  503 Hospital  455 Unit Intercom System Controls   456 16 Doctor’s Orders: Procedures and Hospital Information Systems   456 Process  506 Pneumatic Tube System   458 Doctor’s Orders: An Overview   506 Confidentiality  458 Understanding Doctor’s Orders   507 Computers  458 When Orders Are Written and by Whom   507 Security of Patient Information   459 Content of an Order   509 Security  460 The Orders, the Chart, and Related Responsibilities   509 Security and Emergency Codes   460 Orders: Format, Types, and Management   510 Types of Orders   511 15 Hospital Documents and Procedures   466 Duplicate Orders  516 Bed Management and Patient Flow   467 Orders for Laboratory and Diagnostic Tests   516 Bed Management and Patient Flow: An The Patient Access List and the eKardex   517 Explanation  467 Patient Access List (PAL)   518 How Patient Flow Works   467 The eKardex  519 Interfacility Movement across the Province/ Intervention and Assessment Categories   521 Territory  470 Activities of Daily Living   521 Working in Patient Flow   470 Nutrition  521 Admitting a Patient to the Hospital   470 Clinical Parameters  521 Admission Procedures  470 Lab Results  522 Preparing the ID Band   472 Teaching/Education and Emotional Support   522 Types of Admissions   473 Nursing Interventions  522 Elective Admissions  473 Safety Management  522 Emergency Admissions  474 Respiratory Care  523 Obstetrical Admissions  477 Level of Nursing Care   523 Outpatient Admissions  478 Advance Directives/Level of Intervention   523 Insurance and Type of Accommodation   478 Transfer/Discharge Planning  523 Contents xiii  Order Entry: The Process   523 Activity  557 1. Identify Orders to Be Processed   523 Illness  557 2. Review the Orders for Anything Urgent   524 Nutrition in the Hospital   557 3. Process the Remaining Orders   525 Serving Hospital Meals   558 4. Identify the Orders as Completed   526 The Patient’s Diet   559 5. Check Your Work   526 Types of Diets Ordered and Processing Dietary Orders   559 6. Have Your Orders Checked by the Nurse   526 Therapeutic Diets  559 7. Sign Off    526 Diet Orders and Administrative 8. Fax or Scan the Order to the Pharmacy   528 Responsibilities  562 9. Return the pChart to Its Proper Place   528 Diet protocols for Diagnostic Tests and Surgical Understanding Medication Orders: Your Role   528 Procedures  564 Patient’s Own Medications   528 Postoperative Diets  564 Medications and the Hospital Pharmacist   529 Tube Feedings/Enteral Feeds   566 Categories of Medication   530 Sites of Insertion   566 Medications with Special Directions   531 Tube Sizes  567 Anti coagulant Orders   531 Types of Feeds Ordered   567 Thrombolytics versus Anti coagulants   532 Enteral Solutions  568 Sliding Scale Orders   532 Total Parenteral Nutrition Feeds   569 Medication Orders Related to Lab Values   532 Progressive or Transitional Diet and TPN   569 Part VI   Understanding and 19 Digestion and Excretion   572 The Gastrointestinal System: Common Conditions Applying Administrative Tasks and and Tests  572 Responsibilities  535 Conditions of the Gastrointestinal Tract   573 GI Conditions Requiring Surgery   573 17 Intravenous Therapy  536 Bowel Resection, Colostomy, and Ileostomy   574 Fluids and Electrolytes   537 Administrative Tasks and Medical/Surgical Interventions Indications for IV Therapy   538 and Assessments  575 IV Equipment  538 General Assessments and Interventions   575 IV Bag  538 The Urinary System   579 IV Access Devices   539 Urinary Conditions and Related Tests and Types of Central Line Catheters   541 Procedures  579 The Intravenous Site   541 Urinary Catheters  581 IV Tubing/Infusion Sets   542 Reasons for Catheterization   581 IV Delivery Systems   544 Types of Catheters   582 Electronic Flow Regulators   544 Orders for Catheterization   583 IV Gravity-Based Systems   545 Bladder Irrigation  584 Components of an IV Order   547 Flow Rate  547 20 The Cardiorespiratory Systems   587 Start Date  548 Cardiorespiratory Conditions  588 Types of Intravenous Solutions   548 Myocardial Infarction  588 The Process of IV Order Transcription   550 Cerebral Vascular Accident   589 Blood Transfusions  551 Hypertension  589 Reasons for Blood Transfusion   551 Congestive Heart Failure   589 Preparation  552 Peripheral Vascular Disease   589 Types of Blood Products   552 Cardiac Arrhythmias  589 The Blood Transfusion Process and the Clinical Pneumonia  590 Secretary’s Responsibilities  553 Asthma  590 Chronic Obstructive Pulmonary Disease (COPD)   590 18 Patient Nutrition  556 Respiratory Assessments, Interventions, Tests, and Factors Affecting Nutritional Needs   556 Administrative Tasks  590 Genetics  556 Vital Signs  590 Age  557 Chest Assessments  591 Gender  557 Deep Breathing and Coughing Exercises   591 Pregnancy  557 Pulse Oximetry  592 xiv Contents  Arterial Blood Gases   593 21 Rest and Activity   604 Sputum Specimens  593 Criteria Used in Activity Orders   605 Thoracentesis  593 Physical Energy  605 Lung Scan  594 Physical Capabilities  605 Oxygenation: Supportive Interventions   594 The Nature of the Illness   605 Inhalation Therapy  594 Consciousness and Cognition   605 Wall Oxygen  594 Surgery  606 Artificial Airways and Ventilators   595 Activity Orders  607 Cardiovascular Assessments and interventions   597 Restraints  608 Peripheral Vascular Assessment   597 Equipment Related to Rest and Activity    609 Telemetry  598 Safety and Supportive Care    609 Pacemakers  598 Assistive Mobility Devices    610 Cardiac Catheterization  598 Activities of Daily Living    610 A Sestamibi (MIBI) Scan   598 Chest CT Scan   599 Coronary Angiography  599 Glossary  614 Electrocardiogram  599 Index  621 Treadmill Stress Test   599 Credits  640 Doppler Ultrasound  599 Cardiopulmonary Emergencies  600 Contents xv Preface Administrative and Clinical Procedures for the Canadian Health Professional is a textbook that will prepare the student to work in any type of primary care setting as well as in an acute-care hospital, assuming the administrative responsibilities of a patient-care unit. The comprehensive nature of this book enables the student to graduate knowing the what and the why behind his or her administrative tasks and responsibilities. The student will have the knowledge and background necessary to collaborate effectively with other members of the health care team, facilitating his or her role and contribu- tions to delivering individualized, seamless, high-quality patient care. In most professions, the more related knowledge individuals have, the better they are at what they do. Health administration is no exception. For example, critical thinking skills, and the ability to evaluate situations and set priorities and to triage patients, all require a broad knowledge base about everything from pharmacology to disease processes and treatment protocols. In the hospital setting, either reviewing or transcribing doctors’ orders, the student must understand each order, how it applies to the patient, and what administrative steps he or she must take to ensure the order is properly implemented, from admitting, transferring, or discharging a patient to scheduling diagnostic tests. Increased responsibility has been transferred to administrative health profession- als in all sectors of health care. Primary care settings, hospitals, and other health care facilities need skilled and knowledgeable graduates from postsecondary health admin- istration programs who are prepared to meet the challenges offered in this dynamic field. This book will help the student to meet these challenges. Changes affecting the student’s role function and responsibilities resulting from the COVID-19 pandemic both in primary care and in the hospital setting are included in this edition, adding to its all-Canadian content. ABOUT THE BOOK It is important to note that this textbook covers what in some postsecondary facilities is two separate programs: Health Office Administration (Parts I–IV) and Hospital Unit Administration (Parts V and VI). Other programs offer both Health Office Adminis- tration and Hospital Unit Administration courses of study within one (usually) 2-year program. If you are choosing the chapters that relate directly to hospital unit adminis- tration in order to maximize your students’ understanding of this material, it is essen- tial that you also include Chapters 1 through 8 and Chapter 13 along with Parts V and VI of this book. The following paragraphs present an overview of content offered by the specific parts and chapters. Administrative and Clinical Procedures for the Canadian Health Professional is divided into six parts. Part I (Chapter 1) introduces the reader to the concept, roles, and responsibilities of the administrative health professional. It provides an overview of the attributes, practices, and skills that combine to contribute to the student’s success and professional development in health administration. Workplace settings are dis- cussed along with how to write a résumé and cover letter. You will be introduced to the principles of ethics in health care and the steps required to solve ethical problems. Part II, Health in Context, looks at health and the individual, health and culture, and health in the context of the Canadian health care system. These chapters combine to explain how health affects individuals in a multicultural society and the challenges new Canadians experience as they interface with the health care system. xvii  Chapter 2 discusses the influence health beliefs have on a person’s health behav- iour, considering, as one example, the various responses of Canadians to restric- tions imposed by various levels of government during the COVID-19 pandemic. The health–wellness continuum is discussed—how an individual perceives health, wellness, and illness. The chapter provides the student with both insight into and strategies for interacting effectively with patients and their families in sickness and in health. Chapter 3 is not intended to replace any courses that students may take on culture and health, but it does provide the student with a cursory knowledge of how culture can affect a person’s health beliefs and practices, and how we can best meet people’s health care needs in a culturally sensitive manner. The chapter discusses various issues related to cultural diversity, prejudice, and ethnocentrism. New to this chapter is a dis- cussion emphasizing the importance of recognizing that gender identity and sexual orientation are part of a diverse population and how to meet the unique needs of this population group in a culturally sensitive and respectful manner. Chapter 4 focuses on the principles and practices of the Canadian health care sys- tem. It provides the student with an understanding of the structure and function of health care in Canada. The latest health accord is discussed, along with the controver- sial manner in which provinces negotiated their own terms. The enactment of the Quarantine Act by the federal government at the beginning of the COVID-19 pan- demic is summarized, along with the implications and outcomes for Canadians. The increasing role of the consumer in health care is covered and explains the continued move to a more team-oriented approach to care, particularly in primary care settings— sometimes referred to as the patient’s “medical home.” Part III, Health Care Basics, provides an overview of the knowledge essential for the administrative health office professional in all health care settings. It is important to note that Chapters 5, 6, and 7 should be included in any program preparing the student to work in the hospital setting. Chapter 5 addresses the essentials of standards and safety in the health care setting. Emphasis is placed on quality assurance, the concept of asepsis, Standard Precautions, and infection prevention and control. New to this chapter is a detailed discussion of the COVID-19 pandemic, how the virus is spread, measures to contain and control the spread of the virus, lessons learned, and the implications for health care delivery in the primary care and hospital setting. The use of personal protective equipment is dis- cussed, along with strategies to maintain a safe work environment in the post-pan- demic period. Methods for preventing injury in the health office to patients in various age groups and with disabilities are also highlighted. The chapter also updates the vac- cination protocols for specific provinces. Chapter 6 is designed to provide students with information about laboratory and diagnostic tests levelled to their need, role function responsibilities, and scope of practice within the primary care setting as well as in the hospital. This includes information about when blood tests should be ordered prior to a test, monitoring that must be in place for certain tests (e.g., an INR), and critical values that they should be aware of. New to this chapter is a diagram depicting the life cycle of a diagnostic test, containing the administrative impli- cations for the administrative health professional applicable to each phase. The student’s role in patient education is highlighted, including what type of information he or she can provide the patient with and when it is appropriate to direct the patient elsewhere. The student will also learn how to receive and record telephoned lab reports accurately as well as to whom these results should be reported and when (handling stat orders). Chapter 7 summarizes important information essential for the student to have when working in both the primary care and the hospital setting. The chapter discusses the role of the administrative health professional in patient education, managing xviii Preface requests for prescription repeats or refills, handling and safely storing drugs in the health office, drugs and the law, and how to effectively communicate with the pharma- cist and other members of the pharmacy team. Tips for recognizing drug-seeking behaviour in patients are included. This fifth edition highlights newer technology with respect to electronic prescriptions and related administrative tasks. New to this chapter are frequently used medications grouped in categories and featured in three tables, enabling the student to find relevant information at a glance. The rapidly expanding role and responsibilities of pharmacists across Canada are discussed and newly dis- played province by province in a table. This information is important for the student to have when advising or directing the patient to the pharmacist for related services and support. Part IV, Health Office Procedures, examines the basic administrative needs of the health office: communications, scheduling appointments, provincial/territorial bill- ing, and maintenance of electronic health records. Chapter 8 addresses techniques and strategies to promote effective oral and written communication skills, ranging from communicating over the telephone and interacting with patients in person to techniques for effective interprofessional communication. Strategies for managing irritated and aggressive patients are included. Chapter 9 provides the student with the information about protocols and strategies he or she needs to schedule appointments efficiently in the primary care setting. Patient registration, formerly contained in Chapter 11, has been integrated into this chapter as part of the scheduling process. Various scheduling methods are discussed, with the addition of how to schedule and manage “virtual visits” and “telephone visits,” which have become more prominent since the COVID-19 pandemic. Tips on how to use soft- ware specific to facilitating virtual visits are offered. Chapter 10 expands on the information in Chapter 4, giving details about the struc- ture of territorial and provincial health care plans as well as the systems used to remu- nerate physicians. Other topics include the role of the ministry of health as a payment agency for provincial/territorial health insurance and physician eligibility to submit claims. The concept of “medically necessary” as it applies to insured physician ser- vicers is explained using case examples. The student will understand the process of applying for a health card, as well as criteria affecting the validity of a health card. This chapter will provide the student with the background knowledge required for Chapter 11, The Billing Process, and Chapter 12, Claims Submission. Chapter 11 explains the principles of provincial/territorial billing and details bill- ing procedures and protocols for fee-for-service for primary care organizations. The material presented in this chapter is general in nature, stressing elements that are com- mon across the country. The student will learn the types of patient encounters com- monly seen in a primary care setting and understand the various types of codes necessary to submit a fee-for-service claim (e.g., service, diagnostic, premium, and ther- apeutic codes). Steps necessary to prepare encounters for claims submission are out- lined using case examples. This chapter provides the student with the necessary knowledge to move on to Chapter 12. Chapter 12 discusses the actual process of claims submission and the technologies necessary to facilitate it. The student will learn the various methods to prepare and “batch” claims for submission to the ministry, how to respond to claims error reports, resubmit rejected claims, and understand remittance advice forms. Chapter 13 focuses on health information management, with a focus on electronic medical records and electronic health records. It explains the data entry capabilities of an EMR/EHR clinical management system and includes detailed information on the role of the administrative health professional in managing health information effec- tively and in accordance to federal and provincial confidentiality legislation. Preface xix  Part V, Hospital Procedures, familiarizes students with the hospital environment, hospital policies and procedures, and how the computerized environment affects their tasks from managing doctors’ orders to scheduling tests. Chapter 14 explains the structure and function of various hospital departments and patient-care units as they relate to the role and responsibilities of the clinical secretary. Chapter 15 examines the purpose and structure of electronic health information and documents that are common to most hospitals. The student will learn the adminis- trative responsibilities with respect to admissions, patient flow initiatives, discharges, and transfers. Chapter 16 introduces the student to his or her diverse responsibilities related to physicians’ orders. The basic principles of how to enter/process doctors’ orders are included, as there are still many hospitals where order entry is part of the clinical sec- retary’s responsibilities. In hospitals that have computerized physician order entry, the clinical secretary is still required to understand the orders and respond to administra- tive tasks generated by those orders. This chapter will also provide the student with a general understanding of hospital information systems and how to use them. Part VI, Understanding and Applying Administrative Tasks and Responsibili- ties, builds on the previous Part, providing the student with the background informa- tion required to understand the how and the why behind his or her administrative tasks and responsibilities. Chapter 17 addresses intravenous therapy and related administrative responsibilities. Chapter 18, covering patient nutrition, ensures that the student will understand the types of diets he or she is adding to the eKardex, and sometimes changing. The clinical secretary must also understand how to manage diets as they relate to diagnostic and laboratory tests as well as surgical procedures. Chapter 19 explains the processes of digestion and excretion from a body systems approach. Related procedures, tests, and interventions are explained as they relate to the clinical secretary’s administrative responsibilities. Chapter 20 encompasses the cardiorespiratory systems. The student will gain an understanding of related conditions, tests, interventions, and procedures, enabling him or her to competently carry out related administrative tasks. Chapter 21 addresses the broad spectrum of rest and activity that is ordered for every hospitalized patient. The student will understand the many variations of rest and activity orders, how to process them, and the accompanying administrative tasks that must be carried out. This includes how the patient must be transported to other hospi- tal departments for tests/procedures, when to ensure that a physiotherapist has been contacted, and what assistive devices may have to be requisitioned for a patient. LEARNING FEATURES The following features of this book aim to help students understand, apply, and retain core concepts and ideas: Learning Objectives. Each chapter begins with a list of learning objectives related to key concepts contained within the chapter. Illustrations, Figures, and Charts. Each chapter contains illustrations, figures, and charts to supplement the related text. Key Terms. Key terms are highlighted in the text and defined in the margins for quick reference. These terms and definitions are also consolidated in a glossary at the end of the book. Tip Boxes. Short and salient tips are found throughout each chapter that guide students towards excellence in their future health administration roles. xx Preface  Points to Ponder. Throughout the chapters, Points to Ponder boxes contain infor- mation challenging the student to think about and evaluate scenarios and facts relating to specific chapter content. Chapter Summaries. At the end of each chapter, key points from the chapter are summarized. Review Questions. At the end of each chapter, you will find extensive questions designed to review the content of that chapter. Application Exercises. End-of-chapter application exercises help the student apply skills and knowledge learned in the chapter either through group discussion or independent activities. Websites of Interest. For further exploration of chapter topics, we have identi- fied pertinent websites at the end of each chapter. Student Supplement Workbook: New to this edition is a companion workbook (covering Chapters 1 to 12) that will provide the student with a chapter-by-chapter review of the knowledge and skills required to work as a medical office assistant in a primary care setting. Chapters 1–7 of the workbook includes a variety of questions: true or false, multiple choice, short answer, and critical thinking questions, as well as a case study and a research project. The content in chapters 8–12 addresses a capstone project requiring the students apply theory to practice. Chapters 8–12 (building on content from previous chapters) also guides students through a realistic 2-week workplace simulation in a primary care setting addressing the routine administrative and clinical tasks and responsibilities undertaken by a medical office assistant. These activities include general office procedures, professional communi- cation, setting priorities, critical thinking and decision making, scheduling appointments, and initiating the medical billing process. Upon completion of this simulation, the stu- dent will be better prepared to confidently enter into a workplace experience/externship or directly into the job market. This workbook will direct the student to utilize provincial/territorial online resources provided in the textbook; also identified are community resources and services typically used for patient support and referral in the context of comprehensive primary care initia- tives. All activities in this workbook can be applied to any province/territory. In addition, the workplace simulation can be adapted to use with any program medical software (EMR) or with any other office productivity tools. Instructor Supplements These instructor supplements are available for download from a password-protected section of Pearson Canada’s online catalogue (http://catalogue.pearsoned.ca). Navigate to your book’s catalogue page to view a list of those supplements that are available. Speak to your local Pearson sales representative for details and access. Instructor’s Manual: This manual offers guidance to instructors using the text, including teaching suggestions, solutions to end-of-chapter problems and exercises, and chapter test questions. Transition Guide: New to this edition is a Transition Guide. The guide is presented in table format for users to easily identify changes topic order and presentation from the fourth edition to the fifth edition. The Guide correlates topics, page numbers, and chapters for a seamless move to the new edition. Included in the Guide are notes indicat- ing new section titles, reordering of section, and other structural changes with the text. Preface xxi  PowerPoint Slides: Updated for this edition, these provide a comprehensive selec- tion of slides highlighting key concepts featured in the text to assist instructors deliver- ing the book content. Test Bank: New to the fifth edition, the Test Bank is available as a download in Word format. Each question is accompanied by the correct answer; a Learning Objective refer- ence to the main title; a difficulty ranking of easy, moderate, or challenging; and a desig- nation of recall, applied, or conceptual to indicate the type of learning skill being tested. ACKNOWLEDGEMENTS Publication of a textbook is a collective effort, and this text is no exception. I would like to acknowledge those who have contributed along the way. I am grateful to Heather Jeanes, Clinical Secretary North York General Hospital, for her detailed review of and contribution to Part V of this textbook. Heather’s expert review of those chapters has been critical to ensuring that the duties and responsibilities of the clinical secretary discussed in this section of the book are complete, current, and accurate. Thanks also to Shandra Weyers, Medical Assistant, for the significant review, sug- gestions, and contributions to Part III of this edition as well as to the office simulation in the workbook. Thanks to Sana Zarga, Centennial College, for her role in reviewing the previous edition of this book as well as her significant contribution to the new workbook that accompanies this edition. A debt of gratitude is owed to Joanne Polkiewicz, Pharmacist, for her continuing support. Joanne has done a substantive review of Chapter 7 (Pharmacology) for each edition of this text. Her valuable suggestions for improvement and updates are very much appreciated. Thanks also to Janice Hong, MOA, clinical secretary at Women’s College Hospital in Toronto and Cambridge Memorial Hospital in Cambridge, Ontario, for her valuable contributions to Chapters 14 to 21. I wish to thank Joanna Odrowaz for her expert chapter reviews and thoughtful editorial suggestions. Thanks to Marnie Fletcher, BA, CCHRA(C), Director of Health Information Ser- vices at St. Joseph’s Healthcare Hamilton, who contributed significantly to the initial content preparation and organization of Chapter 13. This chapter has been kept cur- rent and relevant with the assistance of Gail F. Crook, CHE, CHIM CEO and Regis- trar, CHIMA. Thank you, Gail, for your expert assistance and guidance. I am grateful also to Jennifer Purych, published author and educator (former instructor for the Nursing Unit Clerk Program, Vancouver Community College), for taking me on a guided tour of various hospitals in British Columbia, and to Rachel Mann, Maxine Lloyd, and Betty Furtad for updating me on the scope of practice of clinical coordinators in that province. I am also indebted to Heather Geerdink, Presi- dent of the Medical Office Assistants’ Association of British Columbia, for the assis- tance she provided with respect to medical billing in that province. Linda A. Smith, PID, AED, MEd Instructor, HealthCare Communications Management Department, Vancouver Community College, and Paula Castling, HealthCare Communications Management Professor, Nursing Unit Clerk—thanks for your valuable advice regard- ing the role and responsibilities of the unit clerk in British Columbia. I owe a debt of gratitude to the following friends, colleagues, and institutions that have contributed their time, knowledge, and other resources to the development of this book: Dawne Barbieri, MA(Ed), BScN, RN, Director of Interprofessional Practice, Research, and Education, Co-Director of the Centre for Education, North York General Hospital xxii Preface  Elizabeth Barker, RN, BScN, Stratford General Hospital Christy Beavis, Clinical Secretary, Grand River Hospital, Kitchener, Ontario Jennifer Beavis, Workplace Safety and Insurance Board, Ontario Heather Anne Berry, CCHRA(C), BA, HCA(Cert.), Manager, Health Records, South Bruce Grey Health Centre Leslie Brown, Manager, Patient Flow, Stratford General Hospital Rachel Brown, MA, MLIS, Senior Advisor, Knowledge Management/Conseillère principale, gestion des connaissances, Canadian Health Services Research Foundation Glenn Budgell, Regional Director, Medical Care Plan, Newfoundland and Labrador College of Physicians and Surgeons of Ontario Sherry Czekus, Clinical Secretary, Educator, St. Mary’s Hospital, Waterloo, Ontario Michelle de Moor, BSc.PT, MA, CHE, Operations Director, Vancouver Acute Critical Care, Emergency, Trauma Services, Access and Flow, Regional Director Emergency Program, Vancouver Coastal Health Sandra Frisker, Clinical Secretary, St. Mary’s Hospital, Kitchener, Ontario Betty Furtad, Nursing Unit Clerk, Royal Columbian Hospital, British Columbia Penny Giles, RN, BSN, Bedline Manager, Patient Flow-RQBedline, Regina Qu’Appelle Health Region Brenda Hancock, Manager of Medical Affairs and Training, MCP, Department of Health and Community Services, Newfoundland and Labrador Laurie Hauze, Consultant, Provincial Medical Billing Huron Perth Enterprise Information Technology Services Katherine Kelly, Federal/Provincial/Territorial Relations, PEI Department of Health Suzanne Keeptwo, Indigenous Content Consultant & Writer Melissa Kimen, Senior Project Manager, Strategic Priorities Branch, Ministry of Health, Government of Saskatchewan Dr. Grace Langford, MD, FRCP, Stratford, Ontario Maxine Lloyd, Nursing Unit Clerk, Royal Columbian Hospital, British Columbia Gaylene MacDonald, Health Website Project, Corporate Relations and Evalua- tion, Corporate, PEI Department of Health Rachel Mann, Nursing Unit Coordinator, St. Paul’s Hospital, British Columbia Sandy Matos, Freelance Content Manager Maureen McCandless, Director, Communications, The Canadian Chiropractic Association Dr. Matt McDonale, MD, Stratford Family Health Team Dr. Marcie McEwan, General Surgeon, Stratford General Hospital Sandra McKenzie, CMS, Medical Office Manager Medical Office Assistants’ Association of British Columbia Ontario Ministry of Health and Long-Term Care Doug Pinder, RN, BScN, MBA, Ontario Home Health Valerie Pinder, RN, BScN, MEd, Professor, Conestoga College Perri Rattelade, Registered Nurse, ICU Royal Victoria Hospital, Barrie, Ontario Lynn Strugnell, Director Clinical Programs, Huron Perth Healthcare Alliance– Stratford General Hospital Preface xxiii  Dr. Eric Thomas, MD, Stratford Family Health Team Dr. Douglas Thompson, MD, FRCP, Stratford, Ontario Jennifer Wamil, Clinical Secretary, St. Mary’s Hospital, Kitchener, Ontario Nancy White, BScN, Clinical Educator, Maternal/Child, Stratford General Hospital Gail Williams, Accreditation Product Development Specialist (Accreditation Canada) Special thanks go to the following individuals for their help and support: Barb Mines, Clinical Secretary, Medicine, Stratford General Hospital, for sharing her knowledge and experiences with me in the clinical area during several “job shadowing” experiences. Sonia Pagliaroli, RN, MHI(c), CPHIMS-CA, Clinical Informatics, North York General Hospital, for facilitating the use of the many screen captures related to the CPOE environment. Geoff Spooner, Vice-President of Sales and Marketing, Click4Time, for his many emails and valuable information provided about self-registration in health care facilities. Bonnie Thompson, Clinical Leader, Medicine, Stratford General Hospital, for providing me with clinical time on the medical unit. To the following reviewers of earlier editions of this text, I wish to thank: Melinda Vanzanten, St. Lawrence College Muhammad Moin Uddin, TriCare Academy Pauline George, Medix College of Healthcare Silvie Maclean, Fanshawe College To the following participants of our survey, I wish to thank: Cindy Agnoletto, Niagara College Jennifer Ethier, Georgian College Joe Rodrigues, CDI College Nancy Elder, Seneca College Nancy Weatherhead, Conestoga College Vandana Khetarpal, Western Community College I would also like to thank several people at Pearson Education Canada for their professional support, including Cathleen Sullivan, Executive Portfolio Manager, Katherine Goodes, Content Developer, Madhu Ranadive, Content Manager, and Steve Lee, Project Manager. Valerie Thompson xxiv Preface Part I Introduction In Part I of this book, you will learn about the roles and responsibilities of the mod- ern administrative health professional and how your previous work and volunteer experiences can help you. Qualities and skills that promote success in this occupa- tion are outlined, along with the importance of professionalism, scope of practice, and interprofessional collaboration. The principles of ethical practice in health care are also introduced. Chapter 1 The Administrative Health Professional (AHP) Appendix 1A A Sample Résumé Appendix 1B Job Description for a Clinical Secretary 1  Chapter 1 The Administrative Health Professional (AHP) LEARNING OBJECTIVES On completing this chapter, you will be able to: 1. Discuss the various job titles and related employment opportunities available for the administrative health professional. 2. Explain the attributes, skills, and personal qualities an administrative health professional should have. 3. Apply five ethical principles that are relevant to health care settings. 4. Apply the five basic steps to ethical decision making. 5. Describe the administrative and clinical responsibilities the administrative health professional may assume in the primary care setting. 6. Discuss potential working environments considering job prospects, remuneration, and benefits. 7. Demonstrate how to construct a professional résumé and conduct a job search. 8. Detail the importance of continuing professional development. The health care profession is dynamic, complex, and challenging. You are entering it during a time of great change and opportunity. A career path in health administration offers you a wide selection of stimulating job opportunities. The “health office” includes diverse settings ranging from a physician’s private practice and a selection of 2  primary health care team settings to a variety of clinics such as ambulatory or urgent primary health care team settings settings composed of numerous health care. You can also choose to work in a hospital, rehabilitation centre, or transitional professionals from various specialties care or long-term care facility. (e.g., psychologists, physicians, nurses The role of the administrative health professional (AHP) is critical in facilitating [many specialized, e.g., trained in diabetic the delivery of efficient, organized health care in any health-related workplace. Wherever counselling], nurse practitioners, dieti- cians, and social workers). These teams you work, you will be a valued member of a health care team; you will make a significant are located usually in one facility and contribution towards delivering excellent, compassionate, patient-centred health care. may be overseen by an administrative In the primary care setting, although responsibilities are similar, each workplace will have body that hires administrative health professionals, among other responsibili- its own unique job description—some with more responsibilities than others. The same ties. Names for the primary care team holds true if you work in a hospital. What is common, however, is the knowledge, level vary within and among provinces and of competence, versatility, and degree of professionalism required to perform compe- territories. tently as an administrative health professional in any occupational setting. administrative health professional (AHP) a graduate from an accredited health office/services administration pro- LO1 EMPLOYMENT OPPORTUNITIES AND gram who assumes administrative, com- RELATED JOB TITLES munication, and sometimes a mix of administrative and clinical responsibilities in a health care setting. What’s in a Name? The term administrative health professional (AHP) is used as a generic title to represent the diverse roles of graduates from postsecondary health-related administration programs. In the primary care setting, an administrative health professional may be assigned a job title such as medical secretary, medical office assistant, or administrative manager. The title medical office assistant (MOA) is gaining popularity. In hospitals, the titles ward clerk or unit clerk have been widely used for a number of years; more recently those job titles have been replaced with (nursing unit) administrative coordinator, nursing unit assistant, unit coordinator assistant, unit secretary, and clinical secretary. In community nursing, clinical secretary a person working in the term nursing coordinator may be used for the position that often involves arranging a an administrative position on a nursing care unit or other department within the schedule for nurses to visit patients in the community. In this text the term medical office hospital. Numerous other job titles include assistant (MOA) is used to refer to those working in the primary care setting and the unit secretary, ward clerk, or unit clerk. term clinical secretary (CS) applies to those working in a hospital. Client versus Patient Calling individuals seeking health care either a patient or a client has been controversial. The concept of calling a patient (someone seeking or receiving health care) a client was introduced a number of years ago but never really took hold, particularly among nurses, physicians, and other primary care providers. Individuals likewise typically referred to themselves as patients, not clients, of a provider (e.g., “I am a patient of Dr. Suther- land’s,” not “I am a client of Dr. Sutherland’s”). The rationale was that using the term client empowered individuals to become stakeholders in their own health care—to take responsibility for their own health and be active, independent participants in choosing their own treatment options. Client typically represents a person who seeks and pur- chases a product or a service and is, therefore, in control of what that service is and how it is delivered. It was proposed that the term patient put the consumer into a position of subservience to some degree—and the provider (presumably a physician) in a position of power to more or less impose health-related decisions upon the person. In the past, many health care consumers were, to a large degree, dependent on their physician to diagnose their health problem and to recommend and implement a plan of care, much of the time with little discussion. Individuals were quite happy to do what the doctor recommended and they looked to the physician to make these deci- sions—the physician was in a position of power (actual or perceived) and his or her decisions were usually not questioned. Chapter 1 The Administrative Health Professional (AHP) 3  Today, involvement of the individual in every aspect of his or her health care has become the norm. Health care consumers have become more informed about their own health concerns (e.g., by using the internet) and both more proactive and respon- sible for their own health care decisions. The role of the physician has also shifted from sole decision maker to establishing a collaborative relationship with his or her patient in the past, a person seeking or patients in terms of both diagnosis and treatment. As a result, the term patient has receiving health care; the term has evolved and has come to represent an individual who not only seeks health care but evolved to represent an individual who is also actively involved in all aspects of his also is active in making any related decisions. For example, several years ago a labouring or her care, from diagnosis to treatment, mother whose medical condition indicated that she should have a Caesarean section and who assumes responsibility for his or (C-section) would likely have been told by the doctor that the baby was in distress and her health. a C-section would have been booked. Now, a doctor would likely have a conversation with the mom and dad. He or she would explain what was going on with the baby (per- haps a low heartbeat and decelerations on the fetal monitor), and the doctor might recommend a C-section but give the mother the choice of labouring for a limited time to see if things improved (dependent, of course, on the situation). Administrative Health Professional in Primary Care Settings electronic medical record (EMR) a secure electronic medical record that The role of the administrative health professional has changed over the years, becom- includes software and its associated data- ing more responsible and complex (see Figure 1.1). Today, most employers require a base. It is the record that physicians use post secondary certificate or diploma in health-related administrative management. to capture patient information such as a This is necessary for you to acquire the skills and knowledge required to meet the patient’s family history, lab requests and results, cancer screening tests, emergency demands placed on this position. You can see this reflected in the advertisement illus- room visits, prescriptions, and more. trated in Figure 1.1. CENTRAL CLINIC ALBERTA HEALTH SERVICES Medical Office Assistant—Primary Care Start Date: Immediate Job Number 45323 Multidisciplinary team implements primary health care to the surrounding community. Our services include counselling, harm reduction, advocacy, and community development. We interface with multiple community agencies. General responsibilities: You will provide initial and ongoing personal and telephone contact for the professional staff, patients, and visitors. As a member of our primary care health team, you will help facilitate the smooth operation of the clinic’s administrative function, as well as perform administrative and selected clinical duties assisting a variety of health providers (intake interviews, blood pressures, urine and blood sugar testing). You will be the frontline person in triaging patients in accordance with clinic protocol and ensuring that scheduling of patients is done in an efficient, patient-oriented manner. Accountability: The medical office assistant reports to the director of primary care. Qualifications: Certificate or diploma from a community college health office /services administration program or equivalent and/or rele- vant experience. Must have a pleasant, outgoing personality and strong interpersonal skills, along with excellent oral and written communication skills. Must be able to work in a team environment as well as independently, work effectively under stress, and problem solve; must be detail oriented and have proven time management and organizational skills; must be flexible, able to multitask and set priorities. The successful applicant must have in-depth knowledge of electronic medical record (EMR) operating systems, provincial billing practices and procedures, and a keyboarding speed of at least 50 wpm; proficiency in QuickBooks and Microsoft Word is essential. Salary Range: $18–$ 22 per hour depending on education and experience. Negotiable. Figure 1.1 An advertisement for an administrative health professional in a physician’s office or clinic 4 Part I Introduction  In the primary care setting, the administrative health professional must have a broad but somewhat specialized knowledge and skills base. For example, he or she must be com- puter literate (including the ability to navigate electronic medical software and EMR sys- tems) and knowledgeable about provincial/territorial billing, medical office procedures, and protocol. He or she must have basic knowledge of pharmacology, laboratory and diagnos- tic tests, ethics, and human relations. In addition, the AHP must have an in-depth com- mand of medical terminology and outstanding communication skills. If you work in an acute-care hospital, you will require most of the same skills and knowledge base in addition to the ability to carry out the specific responsibilities required of the clinical secretary/ward clerk. These responsibilities include interpreting and transcribing physician’s orders, as well as the administrative tasks related to admitting and discharging patients. Employment Opportunities Positions As previously mentioned, job opportunities are variable, depending on the general area you want to work in. The following briefly describes some of the more common positions as well as the workplace settings you can consider. Medical Office Assistant (MOA) A medical office, clinic, or primary care team could not function effectively without a medical office assistant (MOA). The responsi- bilities of an MOA may be strictly administrative or both administrative and clinical in nature. The range of responsibilities and scope of practice depend on the job descrip- scope of practice working within the tion and the workplace settings. Administrative tasks encompass all aspects of medical boundaries of one’s skill set and job description and/or those outlined by one’s office management, from scheduling appointments to provincial/territorial billing. professional association. Clinical responsibilities may include taking vital signs, preparing patients for proce- dures, facilitating the procurement of patient-driven health histories, preparing the examination or treatment room, autoclaving and sanitizing instruments, providing patients with educational material and answering related questions (e.g., preparation for diagnostic tests), assessing patient need when scheduling appointments, triaging patients, and responding to or directing phone calls. Integrating some clinical responsibilities into the MOA’s job in the office or clinic setting is not new and depends on the occupational setting. MOAs are expected to be multiskilled, versatile, and cost-effective health professionals. In some offices the MOA assumes expanded duties, such as giving allergy shots and assisting with procedures. The MOA must be trained by the physician to carry out these tasks or take courses to receive a certificate qualifying the MOA to perform a particular skill. If an MOA is trained on the job by the physician, performing a skill is considered a delegated act; this means that the health practitioner involved takes responsibility for the employee’s actions. Taking courses at a community college enables you to perform a variety of clinical tasks (e.g., give intramuscular injections, draw blood, take blood pressures). Being certified to perform such tasks is preferable to being trained on the job in some ways. For example, if you have a certificate you can present that as proof of your skill set in another workplace setting. In addition, you are more likely to receive in-depth theoretical knowledge and practical training in an educational context. Administrative Nursing Coordinator Community agencies supply a range of in- home medical services. The administrative nursing coordinator would assist in provid- ing discharged patients with home-based nursing care if the patient required ongoing care and assessment. The same would apply to patients living at home with acute or chronic and complex illnesses who require home care support. The acuity of care for patients requiring home care support is increasing. Commu- nity nurses start and maintain intravenous (IV) therapy in the home, apply or change dressings, and, at times, maintain and monitor patients on ventilators. These patients Chapter 1 The Administrative Health Professional (AHP) 5  may have chest tubes and other complex medical devices. Patients are routinely admit- ted to the agency’s services and discharged when their need for care terminates. Each agency needs someone in an administrative role to coordinate the agency’s needs and activities. The administrative nursing coordinator is aware of the caseloads of the nurses, assigns new admissions based on caseload and priority, conveys vital informa- tion about patients’ medical needs, and keeps track of admissions and discharges. To take on this role, you must be aware of the responsibilities of the various types of nurses within the organization and the related scope of practice for each group (discussed in detail in Chapter 14). You must be able to prioritize information and be familiar with medications, critical lab values, and other components of community care. clinic a facility providing medical care Clinic Administrator/Manager Over the past few years, more clinics have on an outpatient basis. It may be free- appeared, such as central clinics associated with primary care groups or clinics pri- standing or associated with a hospital. Many clinics have a specialty, such as vately owned and operated by independent practitioners (e.g., physiotherapists). ongoing care for orthopedics or cancer. The At medical clinics, services include a complete range of care from family medicine to term is currently also applied to primary day surgery. Clinics such as Preventous Collaborative Health in Calgary provide a range care groups that offer out-of-office ser- vices where rostered patients can seek of preventive health care services (these services are not covered by provincial/territo- medical care when their physician is rial plans). A clinic may offer one service or a variety of services by more than one unavailable. health professional. Managing the administrative needs of a clinic requires excellent organizational skills and the ability to make sound d