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Table of Contents
Student Manual
Acknowledgement
Course Developer MedPro A Division of ECPI University Development Team Marie Twigg, BS, A+, Network+, Security+,
Project+, Linux+, Server+, CTT+, HIT, i-Net, CDIA+, MCT Ryan Scott Williams, BS, MCSE, MCT, VCP, EMCPP, HIT Randal Beard, M.Ed, CPA, RMA
Table of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
The Healthcare Challenge for IT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Module 1
HEALTHCARE FUNDAMENTALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Editing Team Larry Hill, BS, RMA, AHI Trudy Gaba, BA English Joseph Price, A+, Network+, MOUS Christie Adams, MOUS Layout and Graphics
Module 1 UNIT 1
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Organizational structures and different methods of operation. . . . . . . . . . . . . . . . . . . . 16 Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Private Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Nursing Homes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Assisted Living Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Home Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Hospice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Ambulatory Surgery Centers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Medical Departments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Code of Conduct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Adapting procedural behavior to different situations and environments . . 29 Adapting social behavior based on sensitivity of the environment. . . . . . . . 30 The need to follow medical precautionary guidelines. . . . . . . . . . . . . . . . . . 31 Hand Cleaning Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
LIMITATION OF LIABILITY
Every effort has been made to ensure complete and accurate information. Neither MedPro, the developers or publisher can be held legally responsible for any mistakes in printing or for faulty instructions contained within this course. MedPro reserves the right to revise this manual and make changes from time to time in its content without notice. The contents of this material were created for the CompTIA Healthcare IT Professional Certification exam (HIT-001) covering the CompTIA certificate objectives that are current as of 01/12. For additional manuals, and/or volume purchase programs, contact: sales@medpro.ecpi.edu or call 757-419-3700.
Module 1 UNIT 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Basic Clinical Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Module 1 UNIT 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Medical Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
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Student Manual
Table of Contents
Table of Contents
Student Manual
Module 1 UNIT 6
Module 2
Module 2 - UNIT 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Types of Computers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Module 3
NETWORK FOUNDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Module 2 - UNIT 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Medical Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Module 2 UNIT 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Peripheral Maintenance and Troubleshooting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Keyboard Maintenance and Troubleshooting . . . . . . . . . . . . . . . . . . . . . . . . . 62 Mouse Maintenance and Troubleshooting . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Monitor and Display Device Maintenance and Troubleshooting . . . . . . . . . 63 3D video . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Troubleshooting and Maintaining Printers . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Ports and Connectivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Module 2 - UNIT 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Computer Troubleshooting and Maintenance Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Maintaining and Troubleshooting the Computer Operating System . . . . . . 71 Preventive Maintenance and Troubleshooting . . . . . . . . . . . . . . . . . . . . . . . . 73 Motherboard Maintenance and Troubleshooting . . . . . . . . . . . . . . . . . . . . . 74 Power On Self Test (POST) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Power Supply Unit (PSU) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Basic Input/ Output System (BIOS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Complimentary Metal Oxide Semiconductor (CMOS) . . . . . . . . . . . . . . . . . . 78 Unified Extensible Firmware Interface (UEFI) . . . . . . . . . . . . . . . . . . . . . . . . . 78 CPU Maintenance and Troubleshooting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 RAM (Random Access Memory) Maintenance and Troubleshooting . . . . . 80 Expansion Card Maintenance and Troubleshooting . . . . . . . . . . . . . . . . . . . . 80
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Student Manual
Table of Contents
Table of Contents
Student Manual
Ethernet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Computer Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Application Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Application Languages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Medical Devices in the Medical Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 Interface Problems with Healthcare Devices . . . . . . . . . . . . . . . . . . . . . . . . 164
Module 5
Module 4
Module 6
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Module 4 - UNIT 1
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Student Manual
Student Manual
Compatibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196 Daily Business Expectations and Upgrades . . . . . . . . . . . . . . . . . . . . . . . . . . 196 Software Modules and Troubleshooting . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Support and Troubleshooting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Module 7
Module 8
SECURITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
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Student Manual
Student Manual
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285 Information Technology Business Continuance and Disaster Recovery Plan . . . . . . . . 285 Executive Summary: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285 Disaster Recovery Summary: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285 Solution Design: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287 RTO LEVEL I Functional Priority: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289 RTO LEVEL II Functional Priority: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Brittania Health Systems Hands-on Virtual Labs . . . . . . . . . . . . . . . . . . . . 356 GLOSSARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383 INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408
Module 9
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Student Manual
Introduction
Introduction
Student Manual
Introduction
CompTIAs Healthcare IT Technician is a vendor neutral Professional Certification. The CompTIA Healthcare IT Technician Professional Certification is designed to validate IT professionals have the operational, regulatory, and security knowledge necessary to provide hardware and software support in medical environments where electronic health record systems are being deployed and/or maintained. Additionally, the Professional Certification illuminates a commitment to work with, as well as, empathize with the needs of Healthcare professionals by understanding the organizational behaviors and practices of a licensed Healthcare Organization. This course provides an individual with the knowledge and skills required to implement, deploy and support Health IT systems in various clinical settings. Upon completion of the course, candidates will understand regulatory requirements, healthcare terminology and hold an understanding of practical workflow while adhering to code of conduct policies and security best practices. The course prepares students for CompTIAs HIT001 Professional Certification exam. About the HIT-001 Exam: Exam Duration: 60 minutes Number of Questions: 60 Passing Score: 650 on a scale of 100-900 The below table displays the domain areas measured during the examination, along with the approximate degree to which they are represented in the examination as per CompTIAs objective guidelines. Domain 1.0 Regulatory Requirements 2.0 Organizational Behavior 3.0 IT Operations 4.0 Medical Business Operations 5.0 Security TOTAL % of Examination 13% 15% 26% 25% 21% 100%
The Information Technology profession is generally in the practice of meeting the needs of common professional business and enterprise verticals that may relate to Defense, Legal, and Financial Institutions. The Healthcare industry is one of the most challenging vertical markets for Information Technology today with regulatory requirements and dynamic laws that must be met. Healthcare IT continues to grow, as demand has increased due to Government regulations, Healthcare Reform, the American Recovery and the Reinvestment Act. More than 88.5 billion was spent by providers in 2010 on developing and implementing Electronic Health Records (EHRs), health information exchanges, and other Health Information Technology (HIT) initiatives. According to the study conducted by the University of San Diego, HealthCare IT tops the list of hot careers and is expected to grow by 20% thru 2018. Healthcare continues to be a highly challenging and rewarding career choice in the field of IT. The processes that are governed within a given healthcare organization rely heavily upon the applications, systems, and networks that support the processes and which processes are directly related to patient care and accessing life-saving data. Computers have become the critical tool of choice for patient care. Confidential and critical information must be efficiently stored, gathered, reported, and diagnosed by healthcare professionals and specialists. An IT professional in Healthcare needs to understand how essential their role is within an organization, being cognizant to perform with high security, optimal efficiency and under the most stressful circumstances. Medical professionals need to understand how to use and optimize the automated tools available to provide comprehensive patient care. Creating a centralized understanding between the IT professional and Healthcare professional creates a powerful infrastructure to support the evolving medical industry.
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Student Manual
Student Manual
ICON GUIDE:
MODULE INTRO Introduction to the Module.
NOTE-TAKING Throughout the module, participants will notice ample area on each page for note taking. WARNING A note of warning!
MORE INFO More Information on this topic can be found in the Module/Unit referenced.
REVIEW Q Review questions to help test what the participant has learned.
HANDS-ON LAB A hands-on lab for participants to practice skills learned during this module. SLIDE A slide accompanies the material.
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Student Manual
Module 1 UNIT 1
Module 1 UNIT 1
Student Manual
Module 1
There are other types of hospitals that include: Trauma centers Rehabilitation hospitals Childrens hospitals Geriatric hospitals Psychiatric hospitals Hospice centers
HEALTHCARE FUNDAMENTALS
Working in a healthcare setting can be different from other industries. Its important that a clear understanding of the industry, challenges and requirements of this market be understood to properly support the unique necessities of the healthcare field. This module will provide you an overview of a healthcare organization as concepts of the different types of healthcare structures, different departments, different roles and responsibilities, different communication behavior requirements, clinical terms and medical interfaces are presented. Upon conclusion of this module, you will have an overview of the healthcare terminology and environment that is needed for an IT Healthcare Technician.
Private Practice
Private practice or clinics may include a single physician, multiple physicians, or a physician practice with a Physician Assistant (PA) or Nurse Practitioner (NP). This type of practice may be general or specialized. A general or family practice will see most ages of patients and refer patients to a specialist if needed. With most health maintenance organizations (HMOs) insurances, these providers are the primary care physician (PCP). The PCP is the gatekeeper the patient must see before going to a specialist. Examples of specialty clinics would include: Dermatology Ear, Nose and Throat Neurology Psychiatry Pediatric Womens clinic (OB\GYN) Ambulatory (same day) Surgery Ophthalmology Gastroenterology
Module 1 UNIT 1
Hospitals
Most people think of a general hospital when they hear the word hospital. A general hospital is set up to deal with many kinds of diseases and injuries, and may have an emergency department to deal with immediate and urgent threats to health. They often have acute services such as an emergency department, burn unit, surgery, or urgent care. The acute services may include more specialized units such as cardiology or coronary care units, intensive care units, neurology, cancer center, and obstetrics and gynecology departments. Support units in a hospital usually include a pharmacy department, pathology department, and radiology department. On the non-medical side, there often are Medical Records Departments, Information Management Departments, Maintenance Departments, Dining Services, and Security Departments.
Nursing Homes
A nursing home or skilled nursing facility is a place for people who dont need to be in a hospital but can not be cared for at home. Most of these facilities have nursing aides and skilled nurses on hand 24 hours a day. The physician is not always at the facility but the patients personal doctor or a staff doctor is available by phone. The doctors examine patients and review the nursing notes periodically. The staff provides medical care, as well as physical, speech and occupational therapy. Some nursing homes have special care units for people with serious neurological problems such as Alzheimers disease and other forms of dementia.
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Student Manual
Module 1 UNIT 1
Module 1 UNIT 1
Student Manual
Examples of skilled home health services include: Wound care for pressure sores or a surgical wound Physical and occupational therapy Speech-language therapy Patient and caregiver education Intravenous or nutrition therapy Injections Monitoring serious illness and unstable health status
Examples of other home health aide services that may be available include: Help with basic daily activities like getting in and out of bed, dressing, bathing, eating, and other matters of personal hygiene Help with light housekeeping, laundry, shopping, and cooking for the patient
Hospice
The goal of hospice care is providing comforting care by relieving symptoms and supporting patients with a life expectancy of up to six months or less. Hospice involves a team approach with the medical personnel and family to provide medical care, pain management and emotional, as well as spiritual support. The emphasis is on comfort, not curing. Hospice may be provided in the patients home or in a free standing hospice facility.
Home Healthcare
Home health care is a wide range of health care services that can be given at home. The goal of home health care is to treat an illness or injury without the patient traveling to a medical treatment facility. Home health care allows the patient to maintain their independence, and become self-sufficient as soon as possible. Home health care includes part-time or intermittent skilled nursing care, and other skilled care services like physical therapy, occupational therapy, and speechlanguage pathology (therapy) services. Services may also include medical social services or assistance from a home health aide.
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Student Manual
Module 1 UNIT 1
Module 1 UNIT 2
Student Manual
Module 1 UNIT 2
Medical Departments
Healthcare organizations are large and can be made up of many medical departments. Departments are typically recognized by an area of specialization. In many cases, the departments can be represented with both inpatient and outpatient available care. Often, one may hear the terms outpatient or inpatient used when referring to a type of diagnostic or therapeutic procedure. Inpatient means that the procedure requires the patient to be admitted to the hospital, primarily so that he or she can be closely monitored during the procedure and afterwards, during recovery. Outpatient means that the procedure does not require hospital admission and may also be performed outside the premises of a hospital.
Here you will find a list of the medical departments and notations of whether the department is typically seen as inpatient, outpatient or both.
DEPARTMENT Obstetrician/Gynecology (OB/GYN) DEFINITION This branch of medicine includes providing care for all phases of pregnancies, as well as, a wide variety of genital tract diseases in women. INPATIENT/OUTPATIENT INPATIENT OUTPATIENT
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Student Manual
Module 1 UNIT 2
Module 1 UNIT 2
Student Manual
ONCOLOGY
This field covers the study of tumors, both benign, or noncancerous, and malignant, or cancerous. Oncologists are specialized physicians who diagnose, treat, and provide information on preventive measures against tumors. Cancer registrars, who also work in the Oncology field, are specialists in cancer data management.
INPATIENT OUTPATIENT
PEDIATRICS
This is the medical specialty OUTPATIENT that deals with the care and INPATIENT development of children from birth to usually age 18, as well as, the diagnosis and treatment of all childhood diseases. FBC, or Family Birthing Cen- INPATIENT ter, as well as L & D (Labor and Delivery), are specialized units in an inpatient hospital setting that deals with the care of newborns. In Family Birthing Centers, every attempt is made to accommodate the expectant mother and a select number of family members, to experience and share in the birthing process. These centers attempt to simulate a more domestic, home-like setting, while still providing quality care for the mother and newborn. The NICU is the Neonatal (newborn) Intensive Care Unit, which provides life-sustaining care for newborns who face serious medical conditions after delivery.
These specialized units in an inpatient setting provide highly specialized care for critical patients. The ICU is the Intensive Care Unit whose patients are closely monitored after they have been stabilized either from a traumatic accident, chronic medical condition, or after major surgery. The CCU, or Cardiac Care Unit, specializes in the care of cardiac patients.
INPATIENT
Family Birthing Center (FBC) Labor and Delivery (L&D) Stork Neonatal Intensive Care Unit (NICU)
The PCU, or Primary Care Unit, provides compreTransitional Care Unit (TCU) hensive acute and chronic medical care in the same environment, with maintenance in continuity of care and physician-patient relationships. A TCU, or Transitional Care Unit, is an environment that bridges the gap between acute care (immediately after surgery) and patient self-reliance such as going home. MED/SURG
INPATIENT
This unit, in an inpatient INPATIENT hospital setting, provides care for post-surgical patients without serious complications, and for those patients who have been diagnosed with an acute or chronic medical condition that requires hospitalization.
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Student Manual
Module 1 UNIT 2
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PSYCHIATRY/BEHAVIORAL HEALTH
This specialty can be either in a hospital setting, or in an out-patient clinic. This branch of medicine deals with patients that are suffering from mental and emotional issues that could stem from a wide variety of reasons and causes. The treatment of these patients may result in long-term therapy.
INPATIENT
The Post- Anesthesia Care INPATIENT Unit, or more commonly called the Recovery Room, is a unit close in location to the suite of Operating Rooms where patients that have just undergone surgery are sent to be monitored. The objective of this unit is to ensure the patient remains stable before they are admitted to the proper ward or unit within the hospital. Operating Rooms are usuINPATIENT ally in a suite- type setting where rooms are typically designed in pods close to each other. They are utilized for major surgical procedures that usually involve unconscious sedation and anesthesia. ORs are all sterile environments and access is limited.
Emergency Rooms or INPATIENT Trauma Centers provide for the emergent care and treatment of patients with life-threatening injuries or critical medical conditions that are unstable. Many also have a special section, sometimes called FastTrack. Fast-Track provides care for minor acute illness and injuries. The patients who are placed here for treatment usually could not get a same-day appointment with their Primary Care Provider, or they do not have medical insurance. A UR is considered a step below the ER and handles cases on an unscheduled walk-in basis. These facilities treat patients that may require immediate care but the matter is not serious enough to warrant a visit to an ER.
Plastic Surgery
This specialty provides a OUTPATIENT variety of care either in a hospital setting or in an outpatient clinic. Some of the services provided are reconstructive surgery, liposuction, face-lifts, breast augmentations and postburn patient skin grafting to name a few.
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Module 1 UNIT 2
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Student Manual
Patients are treated for OUTPATIENT either surgical or medical conditions involving the upper respiratory system. These specialists are called Otolaryngologists. They provide a variety of services from outpatient minor chronic conditions up to and including surgery. This area of medicine OUTPATIENT includes the care, diagnosis and treatment for all diseases and conditions concerning the lungs. These specialists primarily serve in a hospital setting, but some Respiratory Therapy Specialists and Technicians can also provide treatments in a home-care setting, or in skilled nursing facilities. These two specialties are OUTPATIENT interlinked to a certain degree. Both Physical and Occupational Therapists provide rehabilitative care for patients who have suffered from strokes, spinal cord injuries, traumatic amputations, or injuries that do not allow these patents full use of their extremities, or loss of vision, hearing or speech. The main goal in this specialty is to return as much function back to the patient as possible. This usually includes long-term therapy in an outpatient setting.
These outpatient clinics provide minor surgical procedures that do not require general anesthesia. As the name implies, these patients are treated and released within the same day. Uncomplicated followups occur on an outpatient basis as well.
OUTPATIENT
RADIOLOGY
This supportive area of OUTPATIENT medicine provides imagining studies which aid the physician in the diagnosis of illness and disease. These tests include Xrays, Magnetic Resonance Imaging (MRIs), Computer Tomography (CT) Scans and Positron-Emission Tomography (PETs) to name a few. These tests can be completed in both inpatient and outpatient environments. This supportive clinic provides for the collection, analysis, and results of a multitude of urine, blood and other body fluids test that are ordered by a physician. Laboratory services can be provided in a hospital, emergency room, or stand alone outpatient clinics. These tests also aid the physician in properly diagnosing diseases. OUTPATIENT
LABORATORY
OPTHALMOLOGY
This branch of medicine OUTPATIENT deals with conditions, injuries and diseases of the eye. Opthalmologists can prescribe medication and perform surgical procedures on the eye, as well as, conduct various types of visual screenings.
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Module 1 UNIT 2
Module 1 UNIT 3
Student Manual
DERMATOLOGY
This medical specialty OUTPATIENT provides diagnosis and treatment of conditions pertaining to the skin and accessory organs, which include the hair and nails. Dermatologists usually work in an outpatient setting. Typically found within a OUTPATIENT hospital setting, this specialty involves the injection of radioactive isotopes into a patient as part of an imaging study, or to ascertain structural function of an organ. Strict guidelines must be followed when dealing with radioactive material . Cardiovascular services that OUTPATIENT are frequently offered as an outpatient can be quite varied. They may include monitoring and control of hypertension, most often through medication, pacemaker monitoring, and lipid control through medication. This may also involve ongoing rehabilitative services after a cardiac and Vascular Testing, EKGs, Echocardiograms, Event Monitor, Holter Monitor, Stress testing (Includes Stress Echo and Exercise Tolerance Tests), and Vascular Ultrasound.
Module 1 UNIT 3
Code of Conduct
NUCLEAR MEDICINE
CARDIOVASCULAR
Communicating in the medical field can be difficult, if you are not prepared. Although the average American reads and speaks on an 8th or 10th grade level, the medical professional has had 14-20 years of education. They often speak using medical jargon, which allows them to be concise and precise as they communicate. Though extremely educated in their field of expertise, you may be working with non-IT professionals. Time is critical in this field and concise, professional communication is essential. Every profession has its own jargon and we often forget to change our vocabulary as we talk with those outside of our field of expertise. It is a team effort to communicate, as the speaker must ensure that they are not only heard, but understood. However, it is also the listeners responsibility to indicate what they heard and did not understand. Learning some of the basic medical terminology and the roles of the different medical professionals will make working within the medical field easier and you more efficient.
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Student Manual
Module 1 UNIT 3
Module 1 UNIT 3
Student Manual
Examples of such environments: Imaging rooms - if the units are active you may be exposed to radiation from x-rays or computer tomography (CT) scans. In contrast, a magnetic resonance imaging (MRI) uses a strong magnetic field, which will not only attract metallic items, but deactivate any cards that use data strips such as credit cards, or security badges. Procedural room - a variety of procedures may take place such as, sterile dressings, suture removal, minor surgical procedures (removal of cysts, drainage of abscesses, or scar revision), gynecological procedures, catheterizations or applications of plaster casts. Recovery room - patients arrive just out of surgery, and although not in a sterile environment, the patents are still in a precarious condition. They are being monitored constantly for signs of danger. Examination room - general room to talk with patients and to perform non-invasive procedures. Float room also referred to as a prep room, temp room, or holding bay this room consists of an area that is used to temporarily house patients in transition between their patient room and another location. One example is after tests or surgeries. Emergency room - The emergency medical department (EMD) is at times almost a whole hospital environment in itself. There may be xrays, minor surgical procedures, cardiac procedures, laboratory procedures, and general exams being conducted at the same time. Patients are often in pain and may be dying. The staff will be hurried using quick precise movements to get as many patients seen and treated as soon as possible.
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No part of the student manual can be reproduced in any form without prior written permission from MedPro.
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Student Manual
Module 1 UNIT 3
Module 1 UNIT 4
Student Manual
Module 1 UNIT 4
Basic Clinical Terms
During your time in the medical facility you may hear various medical terms. Although you may not be directly affected, it may require the attention of the staff around you. Some common medical terms may be:
When cleaning hands with soap and water: Wet hands with warm water. Dispense one measure of soap into palm. Lather by rubbing hands together for 15 seconds, covering all surfaces of hands and fingers. Rinse hands thoroughly. Dry hands with paper towel. Use a paper towel to turn off faucet. Discard the paper towel in the trash container. When cleaning hands with alcohol gel: Dispense one measure of gel into palm of one dry hand. Rub hands together covering all surfaces of hands and fingers until dry, about 15 to 20 seconds.
Medical imaging Images of body parts, tissues, or organs, which are used to make clinical diagnosis. Imaging includes not only x-rays, magnetic resonance imaging (MRI), positron-emission tomography (PET), and ultrasound, but other studies as well. Primary Care Physician (PCP) - A Physician, Physician Assistant, or Nurse Practitioner is usually the first contact for a person with an undiagnosed health problem. Typically, the PCP has specialized in family or general practice medicine. They are the gatekeeper for admission to the insurance companys system. HMO patients must see their PCP and get a referral prior to going to a medical specialist. STAT - Comes from the Latin word statim which means immediately. In the medical world it is said and written when something is urgent and needs to be done in a rush. Acuity - Sharpness or clarity of vision or of perception.
Conform to requirements set forth by the project manager: You should always conform to all specified requirements as you begin a project. You may be tasked to work in an environment that requires precautions, or to work around scheduled times when specific areas are not in use by patients or staff.
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Code Blue/Rapid Response - A slang term used by medical staff to refer to a patient in cardiopulmonary arrest. A team of trained providers (called a code team) rush to a specific location with specialized medical drugs and equipment and initiate immediate resuscitative efforts. They are also called a rapid response team.
No part of the student manual can be reproduced in any form without prior written permission from MedPro.
No part of the student manual can be reproduced in any form without prior written permission from MedPro.
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Student Manual
Module 1 UNIT 4
Module 1 UNIT 4
Student Manual
Some facilities may use other terms to avoid alerting patients, such as Dr. Blue. Hospital Trauma Level - Hospitals have designated trauma levels based on the emergency services they provide: Level I - A Level I Trauma Center provides the highest level of surgical care to trauma patients. It has a full range of specialists and equipment available 24 hours a day. The Level I center will also have programs of research and education. Level II - A Level II trauma center works in collaboration with a Level I center. It provides comprehensive trauma care and supplements the clinical expertise of a Level I institution. It provides 24-hour availability of all essential specialties, personnel, and equipment. Level III - A Level III trauma center does not have the full availability of specialists, but does have resources for emergency resuscitation, surgery, and intensive care of most trauma patients. Level IV - A Level IV provides initial evaluation, stabilization, diagnostic capabilities, and transfer to a higher level of care. Level V - Provides initial evaluation, stabilization, diagnostic capabilities, and transfer to a higher level of care. It may not be open 24 hours daily, but it will have an after-hours trauma-response protocol. Other schedules or levels used in healthcare involve the levels of controlled substances. There are several drugs that are not accepted for medical use and are unsafe. By comparison, there are drugs used for medical treatment with certain restrictions that may be abused like drugs with no medical use. Drugs with a potential for abuse are controlled by healthcare facilities including pharmacies. The use of e-prescribing ensures correct controlled substance regimens are correctly followed. Best practices for eMAR (Electronic Medication Administration Records) may include the pharmacy being able to track inventory of controlled substances through the use of wristband verification. This may include data input into an Electronic Health record (EHR) via a scanned barcode on a patients wristband.
Controlled Substance Levels - Drugs and other substances that are considered controlled substances under the Controlled Substance Act are divided into five schedules.
Schedule I Controlled Substances - Substances in this schedule have a high potential for abuse, have no currently accepted medical use in treatment in the United States, and there is a lack of accepted safety for use of the drug or other substance under medical supervision. Schedule II Controlled Substances - Substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence. Schedule III Controlled Substances - Substances in this schedule have a potential for abuse less than substances in schedules I or II and abuse may lead to moderate or low physical dependence or high psychological dependence. Schedule IV Controlled Substances - Substances in this schedule have a low potential for abuse relative to substances in schedule III. Schedule V Controlled Substances - Substances in this schedule have a low potential for abuse relative to substances listed in schedule IV and consist primarily of preparations containing limited quantities of certain narcotics. EMR (Electronic Medical Record)/EHR (Electronic Health Record) - The EMR is an electronic record of health-related information on a patient that is created by a single medical organization by providers who are involved in the individuals health and care. This is usually initiated by a specialty clinic that is not responsible for the total care of the patient. The EHR is an electronic record of health-related information on a patient that is created and gathered from more than one health care organization and is managed and consulted by a physician/staff involved in the patients overall health and care.
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No part of the student manual can be reproduced in any form without prior written permission from MedPro.
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Student Manual
Module 1 UNIT 5
Module 1 UNIT 5
Student Manual
Module 1 UNIT 5
Medical Roles
Healthcare institutions are responsible for maintaining patient records in a safe and secure manner. Today, paperless, digital and computerized systems for maintaining patient data are available and have made the medical industry more efficient. As mentioned in the prior unit, the automated system is called Electronic Medical Record (EMR) system. Putting an EMR system into operation is a complex, expensive investment that has created a demand for Healthcare IT professionals and accounts for a growing segment of the healthcare workforce. Implementing an Electronic Health Record (EHR) or Electronic Medical Record (EMR) system inherently changes the way in which information is managed. This includes, but is not limited to, the practices for managing the security of EHR data. Access roles and responsibilities are assigned to support the Health Insurance Portability and Accountability Act (HIPPA) regulations. When implementing an EHR or EMR system a team should be formed to evaluate a facilitys data security needs, determine the best solutions and set security requirements. EHR and EMR systems frequently have Role Based Access Control (RBAC) with predefined profiles that can be assigned. RBACs are designed by the level of access that role needs to be able to appropriately perform their duties. Here is a typical series of patient encounters that involve an EMR system and the necessity for access roles.
The patient checks in at the front desk by an administrator at Britannia Hospital who has access only to appointment and demographic information. When the patient is moved to the examination room, the nurse has security access to record the patients vital health information (weight, blood pressure and temperature) and to confirm his medication list. The attending Physician, then meets with the patient diagnosing the medical problem and issuing orders to the lab. The EMR system allows for each patient encounter to be recorded and to provide each medical provider the access he/she needs to perform their role, while protecting the confidentiality of the patient. In the example above, the three individuals providing a service to this patient all have the appropriate access level of authentication that parallels their role of service. Medical facilities should evaluate how a patients information is stored within their system and determine which staff members have access to patient data and how much data they should be allowed to handle. Access levels should be assigned to allow staff to work efficiently and productively, while maintaining the highest level of security. For example, Clinical roles in an environment include:
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Dental Assistant (DA) Patient Care Technician (PCT) Medical Assistant (MA) Licensed Practical Nurse (LPN)
Module 1 UNIT 6
While the above clinical roles need access to patient medical data, medical office staff, consultants and business clients would have a more restricted access to the EHR or EMR data, which would be dependent upon their specific role. Medical Office Staff roles would include: Nursing Unit Clerk (NUC) Unit Administrator (UA) Project Manager (PM) Office Manager Staff
If healthcare facilities take the appropriate steps to safeguard EHR and EMRs, the threat of security breaches and resulting HIPPA penalties can be minimized while providing patients a level of trust. It is imperative that appropriate access roles and responsibilities be established. Most EMR systems provide a record of accountability. Should any suspicious activity be detected, a detailed record of data access and modification to patient records can be viewed. The accountability reports play a vital role in ongoing security management.
In review of the 10 most common application interfaces, HL7 - Health Level Seven International (HL7) is the global authority on standards for interoperability of health information technology with members in over 55 countries. Hospitals and other healthcare provider organizations typically have many different computer systems used for everything from billing records to patient tracking. All of these systems should communicate with each other (or interface) when they receive new information, but not all do so. HL7 specifies a number of flexible standards, guidelines, and methodologies by which various healthcare systems can communicate with each other. Such guidelines or data standards are a set of rules that allow information to be shared and processed in a uniform and consistent manner. These data standards are meant to allow healthcare organizations to easily share clinical information. HL7 is derived from the OSI model Layer 7 (described in Module 3, Unit 1), where applications communicate and communicate across the enterprise. E-Prescribing defines a new feature for the prescribers ability to electronically send an accurate prescription to a pharmacy from a physician. This allows for an e-prescribing platform in enhancing patient safety. E-prescribing is one of the key initiatives to expedite the adoption of electronic medical records and build a national electronic health information infrastructure in the United States.
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Student Manual
Module 1 UNIT 6
Module 1 UNIT 6
Student Manual
the richness of CCRs clinical data representation, and does not disrupt the existing data flows in payer, provider, or pharmacy organizations. The CCD is an XML-based standard that specifies the structure and encoding of a patient summary clinical document. It provides a snapshot in time, constraining a summary of the pertinent clinical, demographic, and administrative data for a specific patient. CCR - The Continuity of Care Record, or CCR, is a standard developed by ASTM International - a global leader in the creation of consensus standards. Because a CCR document is slightly limited in its ability to become a highly-scalable solution for interfacing two systems, the Continuity of Care Document (or CCD) was invented to link ASTMs CCR with the HL7s Clinical Documentation Architecture. ICD-10 - The International Statistical Classification of Diseases and Related Health Problems, 10th Revision is a medical classification list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. It is maintained by the World Health Organization (WHO). CPT - (Current Procedural Terminology) codes are numbers assigned to every task and service a medical practitioner may provide to a patient including medical, surgical and diagnostic services. They are then used by insurers to determine the amount of reimbursement that a practitioner will receive by an insurer. Since everyone uses the same codes to mean the same thing, they ensure uniformity. CPT codes are developed, maintained and copyrighted by the AMA (American Medical Association.) As the practice of health care changes, new codes are developed for new services, current codes may be revised, and old, unused codes are discarded. Thousands of codes are in use, and they are updated annually. SNOMED CT - (Systematized Nomenclature of Medicine), is a systematically organized computerized collection of medical terminology covering most areas of clinical information such as diseases, findings, procedures, microorganisms, substances, etc. allowing a consistent way to index, store, retrieve, and aggregate clinical data across specialties and sites of care. It also helps organizing the content of medical records, reducing the variability in the way data is captured, encoded and used for clinical care of patients and research. It is a structured collection of medical terms that are used internationally for recording clinical information and are coded in order to be computer processed. It covers areas such as diseases, symptoms, operations, treatments, devices and drugs. SNOMED CT is considered by some to be the most comprehensive, multilingual clinical healthcare terminology in the world. It provides for consistent information interchange and is fundamental to an interoperable electronic health record. It can be used to record the clinical details of individuals in electronic patient records and support application functionality such as informed decision making, linkage to clinical care pathways and knowledge resources, shared care plans and as such support long term patient care. It was originally created by the College of American Pathologists (CAP) and, as of April 2007, owned, maintained, and distributed by the International Health Terminology Standards Development Organization (IHTSDO), a not-for-profit asNo part of the student manual can be reproduced in any form without prior written permission from MedPro.
For example, most electronic medical record systems include e-prescribing features. The workflow may be as follows: 1. Prescriber Two-Factor Authentication -Something you know, and something you have, as described in Module 8, Unit 1 2. Patient Lookup 3. Drug and Regimen selection 4. Allergy and drug reactions noted 5. Selection of alternative drugs 6. Pharmacy Selection 7. Electronic transfer 8. Patient goes to get filled prescription CCD - Continuity of Care Document is the preferred interface standard for communication between EMR software systems and patient portal systems. This is because the CCD standard offers greater scalability in comparison to the CCR standard, as it can grow and will accommodate greater amounts of work. Medical Web Experts has outstanding experience with this technology. The CCD is a joint effort of HL7 and ASTM to foster interoperability of clinical data to allow physicians to send electronic medical information to other providers. The CCD is a CDA implementation of ASTMs Continuity of Care Record (CCR). It is intended as an alternate implementation to the HL7 Clinical Document Architecture. The CCD represents a complete implementation of CCR, combining the best of HL7 technologies with
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Student Manual
Module 1 LABS
Module 1 LABS
Student Manual
sociation in Denmark. NDC ID - The National Drug Code Directory System provides a directory of selected over-the-counter agents, insulin formulations, and prescription drug products, and herbal drugs distributed in the United States. Originally, the system was established by Medicare as part of an outpatient drug reimbursement program and a method to identify drugs during commercial distribution. Data in the NDC is updated quarterly. Drugs listed under the NDC are identified by an 11-digit NDC ID number divided into three segments. The first segment, assigned by the FDA, identifies the vendor (or labeler) involved with the manufacturing, packaging, or distribution of the drug. Product codes, listed in the second segment, comprise the generic entity, strength, and dosage form. The third segment, or package code, indicates the package size. The manufacturer assigns the second and third segments of the code for a given product. PACS - A Picture Archiving and Communication System is a medical imaging technology which provides economical storage of, and convenient access to, images from multiple sources. The universal format for PACS image storage and transfer is DICOM. Non-image data, such as scanned documents, may be incorporated using consumer industry standard formats like the Adobe PDF that may be tied to other metadata. Once encapsulated in DICOM. A PACS consists of four major components: 1. The imaging modalities such as X-ray computed tomography (CT) and magnetic resonance imaging (MRI). 2. Secure PHI Network. 3. Application (EMR) | Imaging Modules / viewers via a Workstation. 4. Archival - for the storage and retrieval of long-term images and relational data. PACS streamlines problems associated with traditional film-based image retrieval, distribution, and display through electronic and secure technologies. E/M Codes - Evaluation and Management Coding is a medical billing process that practicing doctors in the United States must use to be reimbursed by Medicare, Medicaid programs, or private insurance for patient encounters. It is used by private health insurance companies as the standard guidelines for determining type and severity of patient conditions. This allows medical service providers to document and bill for reimbursement for services provided. E/M codes are based on the Current Procedural Terminology (CPT) codes established by the American Medical Association (AMA).
Module 1 LABS
1. Place a check mark next to the facility that is a type of inpatient hospital: ______ Hospice center ______ Assisted Living Facility ______ Psychiatric facility ______ Home health care ______ Nursing Home
2. Which of the following are considered an Outpatient department: a. b. c. Intensive Care Transitional Care Unit Plastic surgery
3. Match the trauma level with the appropriate definition: Trauma Level a. Level I Definition _____This level provides initial evaluation, stabilization, diagnostic capabilities and transfer to a higher level of care.
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Student Manual
Module 1 LABS
Module 1 LABS
Student Manual
b. Level II
_____ This type of trauma center works in collaboration with a Level I center. It provides comprehensive trauma care and supplements the clinical expertise of the Level I institution. It provides 24-hour availability of all essential specialties, personnel, and equipment. _____This type of trauma center does not have the full availability of specialists, but does have resources for emergency resuscitation, surgery, and intensive care of most trauma patients. _____ This trauma center provides the highest level of surgical care to trauma patients. It has a full range of specialists and equipment available 24 hours a day. This center will also have a program of research and education. _____ This level of trauma center provides initial evaluation, stabilization, diagnostic capabilities, and transfer to a higher level of care. It may not be open 24 hours daily, but it will have an after-hours traumaresponse protocol.
5. Match the appropriate Medical Interface with its definition: Interface Name Definition a. CCD _____ The global authority on standards for interoperability of health information technology with members in over 55 countries. _____ Prescribers may send an electronic and accurate prescription to a pharmacy from a physician. _____ Preferred interface standard for communication between EMR software systems and patient portals. Offers good scalability. _____ Limited in its ability to become a highly-scalable solution for interfacing two systems. _____ Maintained by the World Health Organization is a medical classification list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances and external causes of injury or diseases. _____ Codes assigned to every task and service a medical practitioner may provide to a patient including medical, surgical and diagnostic services. _____ A systematically organized computerized collection of medical terminology covering most areas of clinical information such as diseases, findings, procedures, microorganisms, substances, etc. _____ Directory of selected over-the-counter agents, insulin formulations, and prescription drug product, and herbal drugs distributed in the United States. _____ Medical imaging technology which provides economical storage of, and convenient access to, images from multiple sources. _____ A medical billing process that practicing doctors in the United States must use to be reimbursed by Medicaid, Medicare programs or private insurance for patient encounters.
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c. Level III
b. CCR
d. Level IV
c. CPT
d. E/M Codes
e. Level V
e. ePrescribing
f. HL7
g. ICD10
h. NDCID
i. PACS
j. SNOWMED
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Student Manual
Module 1 LABS
Student Manual
TITLE
CompTIA Objective
Organizational Structure
Objective 2.4
Identify organizational structures and different methods of operation c. Imaging room: Organizational Structures Hospital Private practice Nursing homes Assisted living facilities Home healthcare Hospice Surgical centers Methods Differences in scope of work Availability of resources Formality of procedures
d.
e.
Examination room:
UNIT 2
Medical Departments
Objective 4.1
Identify commonly used medical terms and devices Common medical departments Inpatient
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OB/GYN ONC PEDS FBC/L&D/Stork/NICU ICU/CCU TCU/PCU MED/SURG Behavior Health PACU OR/UR ER
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Student Manual
Student Manual
Outpatient OB/GYN OCN PEDS Plastic Surgery ENT Respiratory Physical therapy Cardiovascular Occupational therapy Ambulatory/Day Surgery Radiology Laboratory Ophthalmology Dermatology Nuclear
Acuity Code blue/rapid response Trauma levels Controlled substance (levels) EHR/EMR
UNIT 5
Medical Roles
Objective 2.2
Identify EHR/EMR access roles and responsibilities: MD RN PA DA PCT MA NUC UA LPN PM Office Manager Staff
UNIT 3
Code of Conduct
Objective 2.5
Execute daily activities while following a code of conduct: Communicate in a professional fashion Adapt procedural behavior according to different situations and environments Imaging room Procedural room Recovery room Examination room Float room Emergency room Adapt social behavior based on sensitivity of the environment Use proper sanitation stepsfollow medical precautionary guidelines Conform to requirements set forth by project manager.
UNIT 6
Objective 4.1
Identify commonly used medical terms and devices: Interfaces HL7 E-prescribing CCD CCR ICD10 CPT Snowmed NDCID PACS E/M codes
UNIT 4
Objective 4.1
Identify commonly used medical terms and devices: Basic clinical terms Imaging PCP Stat
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No part of the student manual can be reproduced in any form without prior written permission from MedPro. No part of the student manual can be reproduced in any form without prior written permission from MedPro.
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