The Examining Room Upkeep Procedure details the necessary procedures in keeping the examining rooms clean and list all of the necessary supplies. This procedure applies to all examining rooms. (6 pages, 782 words)
Examining Room Upkeep Responsibilities:
The Medical Office Manager will be responsible for managing all cleaning and waste disposal for the medical office.
The Fee Schedule Notice Template covers medical office visits, immunizations/injections, supplies, and more. Once the doctor has finished examining the patient, the patient will then proceed back to the reception area for checkout procedures. The doctor will bring the patient’s chart up to the front desk, along with the procedure sheet, appropriately filled-out. This sheet will contain the codes that the doctor used to diagnose the patients (ICD-9 Code), as well as the codes used to charge the patient for the visit (CPT Code). MDO103-2 FEE SCHEDULE can be used for a sample Medical Office fee schedule.
If the patient is paying for the visit privately, the receptionist will take the payment from the patient and give them a receipt for the visit, along with a copy of the procedure sheet. The patient may then submit the appropriate forms to their insurance company if they participate with a plan not accepted by the medical office. If the patient participates with an medical insurance policy that is accepted by the medical office, they may be required to pay a pre-set co-payment. The receptionist will take the co-pay from the patient and submit the rest of the bill to the insurance company for reimbursement. The patient will receive a copy of the procedure sheet, if needed.
The HIPAA Authorization Form Template authorizes the use or disclosure of protected health information. By signing this form, the individual understands that he/she may revoke authorization at any time by notifying the healthcare provider in writing. The revocation will only be effective from the date it is received in the office and will not apply retroactively. MDO109-1 HIPAA AUTHORIZATION FORM and the information requested should be kept in each record.
The Office Manager should adopt a written privacy procedure that clearly identifies employees or classes of employees who require access to protected information, how it will be used within the entity, and when the information may be disclosed. To protect patient privacy, employees must take extra precautions, both in structures and in circumstances, not to inadvertently release patient information. Patients may choose to deny the provider from using their information for a variety of reasons. Patients can opt out of any portion of the notice.
The Important Abbreviations Guide Template lists common abbreviations used in a medical office such as twice a day (BID), basic life support (BLS), fracture (Fx), and more. The medical office staff should adhere to certain rules to ensure a safe and professional work environment. All employees will be immunized, have CPR training, and arrive for work dressed in a clean and conservative manner. Medical office staff are required to be uniquely and easily identified as an employee of the medical office.
All office employees must remember to treat patients with courtesy at all times. Office personnel should seem pleasant and helpful to the patients. A pleasant attitude will keep the patients feeling comfortable with the office. It is important to remember to treat patients on the phone with the same courtesy. Patients calling to retrieve test results are often anxious and nervous. They should be treated reassuringly. All employees should be trained and certified in CPR and Basic Life Support (BLS) techniques. Because it is a medical office, employees must be prepared for emergencies.
Patients may want to learn more about certain topics that affect their families by contacting different agencies that specialize in those areas. The receptionist should create and maintain an Information Referrals List Template with the phone numbers for these various organizations in order to give a prompt referral to patients. MDO108-1 INFORMATION REFERRALS lists phone numbers for organizations such as Alcoholics Anonymous, American Diabetic Association, National Kidney Foundation, and more.
The medical office should have literature and phone numbers for information referrals on hand to aid in educating patients on how to care for their physical well being throughout life. It’s important to keep patients educated on disease prevention, general health and recognizing symptoms. The most important step in fighting illness is prevention. In order to prevent illness, it is important to keep patients educated. To this end, patient information should be made available in the office. These will be provided in the form of pamphlets and brochures and will be placed in both the patient waiting area and in patient examination rooms.
The Medical Office HIPAA Procedure (Health Insurance Portability Accountability) describes the background and implications of the HIPAA Act and outlines areas of compliance for a medical office. The medical office should implement and follow the policies and procedures required to become HIPAA compliant.
This statement applies to the requirements outlined by US law and the regulations promulgated by the Department of Health and Human Services (DHHS) regarding security, privacy and confidentiality. These requirements, involve healthcare providers and individual physician offices, and are far-reaching for healthcare transactions and administrative IT systems. All medical offices that maintain or transmit electronic health information, which is considered to be sensitive, must comply by implementing sufficient security procedures to ensure patient confidentiality.
Medical Office HIPAA Responsibilities:
Managers should oversee the implementation of all privacy controls, training, and compliance coordination.
The medical Office Manager should be the HIPAA Coordinator and Privacy Officer responsible for understanding the implications of conforming to HIPAA, ensuring that HIPAA rules are followed, making sure that all office staff are trained on the Medical Office HIPAA Procedure, and that the medical office complies. The HIPAA duties and responsibilities can be assigned to one person in an existing position and do not require any additional staff. The HIPAA Coordinator should have the authority and responsibility to maintain medical records within the guidelines of HIPAA regarding privacy, security, and confidentiality standards.
The Medical Privacy Notice Template states in easily understandable language how a patient’s information may be used. The notice must give examples of how the information may be shared, for instance, between a physician and a nurse or between a hospital and an insurer. The American Hospital Association has developed a model notice that is eight pages long, but there is no standard format.
MDO109-2 NOTICE OF PRIVACY PRACTICES describes your rights and certain obligations the medical practice has regarding the use and disclosure of medical information. The law requires the practice to (1) Ensure medical information is protected; (2) Provide the patient with this Notice describing our legal duties and privacy practices with respect to medical information about him/her; (3) Follow the current terms of the Notice in effect. The practice reserves the right to change the office’s privacy practices and the Notice. They reserve the right to make the revised or changed Notice effective for medical information they already have about patients as well as any information they receive in the future. There should be a copy of the current Notice at the office.
Any supplies that need to be ordered should be written down on the Medical Supply Order Worksheet Template so that a large order may be placed once a week to a medical supply company. MDO105-1 MEDICAL SUPPLY ORDER SHEET covers a description, ID, quantity, unit cost, and more. Each patient room should be kept well supplied with the necessary supplies in order to keep visit times as efficient as possible. The examining rooms should be restocked at the beginning of each day to replenish whatever supplies may have been used during the day before. Each room should be equipped with the following supplies:
Sterile and non-sterile gauze
Sink and soap, and more.
The examining room should be kept clean and fully stocked with necessary medical supplies.
Each patient is required to fill out a New Patient Information Worksheet Template that includes such information as patient name, address, phone number, social security number, past medical history, past and present medication, any allergies to medication, medical insurance information, and a copy of the patient’s insurance card. A patient file must be made for each new patient in order to hold the paperwork required for the patient. One side of the folder should contain MDO101-1 NEW PATIENT INFORMATION SHEET, leaving the other side of the folder free for progress notes, lab work, and any other correspondence between doctors.
The file should be set up in such a manner so that the progress notes that the doctor writes for each new office visit will be directly on top of each other. The other sections should be tabbed with the appropriate headings and again be set up so that the most recent information will be at the top of the section. The patient information sheet needs only to be filled out on the patients first visit to the office. Any changes in patient information in subsequent visits may be updated directly onto the computer system. The computer system also helps to providing quick access to the billing records to resolve inquiries or problems from insurance companies or patients.
New Patient Information Worksheet Template Details
The New Patient Intake Procedure describes the proper procedures for intake of new patients and explains all of the necessary paperwork. It ensures uniformity among all patient files to improve the efficiency of your medical office routine.
The New Patient Intake Procedure applies to all new patient documentation. However, this does not necessarily cover internal or certain day-to-day patient correspondence. (6 pages, 1228 words)
New Patient Intake Responsibilities:
The Medical Office Manager will be responsible for maintaining all patient records and their location (i.e. by wall unit and shelf row number).
New Patient Intake Definitions:
Health Insurance Portability and Accountability Act of 1996 (HIPAA or also known as the Kennedy-Kassabaum Act) is a federal law that amends the Internal Revenue Code of 1986 to limit waste, fraud, and abuse in health insurance and health care delivery and to simplify the administration of health insurance. HIPAA, Public Law 104-191 was signed into law on August 21, 1996. Included in the law is a separate section intended to reduce the administrative costs of health care. HIPAA has varying implementation effective dates for different sections.
Need to Know – A security term used to define access requirements for sensitive or confidential information. The term implies that only those individuals that have a valid purpose or requirement should be allowed access to the information.
The Office Location Procedure articulates the different and important aspects of locating a medical office. The medical office should be located in a convenient, safe location, with parking readily available to staff and patients.
The Office Location Procedure applies to establishing or moving the medical office. (2 pages, 467 words)
When deciding the location of the medical office, convenience is, perhaps, the most important factor. An area that easy to get to, near other important businesses and in a safe neighborhood makes for the ideal location. The safety of the neighborhood must also be considered. Patients want to feel safe and comfortable when they visit the office.
Office Location Responsibilities:
The Office Manager will be responsible for selecting the office location.
The Office Manager should use the Patient Records Access Log Template for each set of records. Medical records, psychotherapy notes, and administration files should be reviewed regularly. Documents that are outdated or no longer relevant should be removed, as should documents that are misleading or inaccurate. The Office Manager should adopt a written privacy procedure that clearly identifies employees or classes of employees who require access to protected information, how it will be used within the entity, and when the information may be disclosed.
MDO109-3 PATIENT RECORDS ACCESS LOG covers the date, who accessed the record, the reason for access, and more. The patient also has the right to know who accessed the records, when, and for what reason. Covered entities will also need to take steps to ensure that their business associates and contractors protect the privacy of health information. Access to employee medical records should be limited to personnel with a “need to know” a patient. A “need to know” should govern access to all employees’ records, including separate personnel files. Those with a need to know typically include only those involved in making decisions about a patient.
MDO103-1 PAYMENT POLICY should be clearly posted in plain view of all patients near the receptionist area. The Payment Policy Notice Template states that payment for services are due at the time of the visit and lists the forms of payment accepted. It also covers insurance issues and the name of the billing manager in case of questions regarding bills. It’s very important to bill patients and insurance companies promptly, and with accuracy.
If the patient is paying for the visit privately, the receptionist will take the payment from the patient and give them a receipt for the visit, along with a copy of the procedure sheet. The patient may then submit the appropriate forms to their insurance company if they participate with a plan not accepted by the office. If the patient participates with an insurance policy that is accepted by the medical office, they may be required to pay a pre-set co-payment. The receptionist will take the co-pay from the patient and then submit the rest of the bill to the insurance company for reimbursement. The patient will receive a copy of the procedure sheet.