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Online Medical Coding Training

Check out a lesson from our Medical Coding program.


Lesson 1
The World of Health Care

Step 1: Learning Objectives

When you have completed the instruction in this lesson, you will be trained to:

  • Describe medical personnel and their role in quality health care.
  • Describe the personal qualities of a healthcare professional.
  • Describe the desirable character traits of a healthcare professional.

Step 2: Lesson Preview

Congratulations for taking the first step toward your new career! Be proud of yourself! You chose a growing, exciting career. Welcome to the exciting world of health care!

You have chosen a terrific time to enter the healthcare industry. Healthcare, in general, has been—and continues to be—one of the fastest-growing employment industries in the United States. Economists and staffing experts claim that while other industries are cutting back and laying off employees, the healthcare industry is in dire need of workers. In fact, according to the U.S. Bureau of Labor Statistics, the United States economy will add 20.5 million new jobs between 2010 and 2020—healthcare practitioners and technical occupations are projected to add 2.0 million new jobs in that time frame.1 Not only will the demand for healthcare professionals increase but the earnings potential is excellent.

The healthcare professional plays a vital role in the medical field, and we have written this course to help you be successful. The course will show you how to manage patient records through many aspects of the medical field, including understanding medical terminology and how to work with medical records. You will learn about today’s technology as it relates to your field of study. You will have the knowledge you need to find the position you want. Also, when you are ready to find that job, we are here to help. We offer graduate assistance to every student who completes our courses. We teach you how to market yourself and how to prepare for your new career. We know you are ready to learn, and be assured that we are ready to teach you—from the very first page until you graduate and are working in the field, we are dedicated to your success.

Now let’s talk a little bit about how your course is organized. Your course is divided into packs, which are then divided into lessons. Each lesson contains skills that you will master on your way to graduation. The lessons are easy to follow and offer step-by-step instruction to make learning simple—even fun!

Congratulations on your new career path! We will help you succeed!

Each new lesson will begin with Learning Objectives and a Lesson Preview. The Learning Objectives tell you what you should learn by the end of the lesson, and the Lesson Preview provides a brief description of the lesson. From there, you will read new material and complete Practice Exercises. This combination of new material followed by a review may repeat two or more times per lesson. This format helps you apply what you learn and retain the information.

Finally, you will take a graded Quiz after each lesson. Quizzes highlight what’s important in the course. You will know many of the items on the Quiz without looking back at the lesson. However, if you don’t remember or aren’t sure of an answer, you can find the information in your lesson. All of your Quizzes are open book! We want you to learn how to use your resources to find the right answer rather than memorize the material.

If you have questions about any part of the course, feel free to contact an instructor. The instructional faculty is available to make your trip through this material enjoyable and rewarding.

Your course materials provide Online Learning opportunities for you to discover more about certain topics. While you will not be tested on the information provided, you are encouraged to participate in the online learning to get the most out of this course.

*Please be aware that website addresses change often. At the time of publication, the website addresses in this course were accurate.

In this first lesson, you’ll study the key players in the healthcare field. You’ll look at a typical day in the life of several healthcare professionals. Finally, you will look at the personal qualities, teamwork and character traits of a successful healthcare professional. First, let’s review how to set goals and manage your time during your studies and in your new career.

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Medical Coding

Step 3: Set Goals

Studies prove that people who set a series of smaller, short-term goals achieve their dreams more often than those who only set long-term goals. Let’s consider a few shorter-term goals—in addition to the date you have in mind to begin your new career!

Take a few moments to write out some short-term goals. For instance, consider submitting your first Quiz today! Set a goal to complete the first three Quizzes by a certain date, or commit to a specific date to complete the first pack, for example. Whatever goals you decide on, do what works for you—make your goals realistic yet challenging.

Just think…in a matter of only a few weeks, you could be working on the next pack! The timeline and choice are yours; only you know what will work best for you.

Yes, you can study at your own pace. It’s not necessary to blaze through a course on your way to earning your U.S. Career Institute certificate. In fact, you could read only one lesson a month if you really wanted to. However, is that a good idea? Do you think that you would remember what you learned each month and be able to build upon it? When it’s time for a Quiz, you’d probably have to put in a lot more study time if you used that approach!

usci coding student

Writing your goals is powerful! Take a moment to set some goals for your course.

Step 4: Time Management

Now, what about time management to help you meet your goals? Well, there’s no denying that time is a valuable resource. Each person has the same amount of minutes and hours available each day. Since you cannot change this fact or borrow time from previous days, all that you can do is use the time wisely. Time management consists of effectively and efficiently organizing yourself to make the best use of the time available and making the choices most appropriate for you. Let’s clarify the difference between effectiveness and efficiency. Selecting the right task demonstrates effectiveness, which allows you to work smarter by working on what is important. Efficiency describes finding the best methods to complete that task.

To learn to manage your time more effectively, identify and set daily goals. Write down your daily goals to make them more visible to you and increase your commitment to them. Time management consultants agree that a daily to-do list is invaluable. Make your list a regular part of your routine. List all of the activities that you want to accomplish that day and rank them by level of importance. The ranking order works well because you rank the activities that allow you to achieve the most important goals first.

One of the most essential tools for effective use of time is a schedule. To begin working on a schedule, set aside a period of time each day to reflect and plan. This brief time spent each day will save you hours in the long run. Also, estimate in advance how much time a particular task will take. For example, pretend you set a goal to successfully finish a particular Quiz by the end of the week. You estimate it will take you six hours to prepare for and complete the Quiz, and you estimate you have two hours available for schoolwork each day. You don’t want to wait until your goal completion date to begin the Quiz because somehow you will be trying to pack six hours of work into two hours. If you do this, you will not meet your goal—either you will not complete the Quiz or you will rush through the Quiz and not perform as well as you originally hoped. Don’t forget to schedule time for breaks and relaxation!

The final step in planning your work is to work your plan. Keep your schedule visible as a reminder of your goals. To finalize your scheduling, keep track of your progress toward a particular goal, and record your accomplishments.

Regardless of how well you plan your goals and schedule your time, you will inevitably run into obstacles. That’s alright—you can conquer these obstacles.

One such obstacle stems from overcommitment. By spending time on what others want, you become unable to concentrate on your own goals. Many individuals do not know how or are afraid to refuse a request. Remember, your goals are important, and it’s okay to politely refuse requests that are not in your best interest!

Another obstacle you may encounter is an inability to delegate, or entrust tasks to others. However, delegating is a key concept in successful time management. If you don’t delegate, the result is less time spent on the critical tasks that need your attention. You often perform activities at work and home out of habit. Try this technique: Whenever you face a task, ask yourself if someone else can handle it. Think about it. Can your daughter throw in a load of laundry while you study? Can your husband drive your son to basketball practice while you work on a Quiz? Probably. So ask them to do so!

Keeping an orderly desk (or study space) can also help you manage time. Your desk can and should be a tool to make you more effective. Michael LeBoeuf, author of Working Smart, offers some guidelines for this topic. For example, keep only one project at a time on top of your desk, making that project your top priority. If you have a Quiz to finish, that should be the only item on your desk. Also, keep items off your desk until you are ready for them. Furthermore, don’t be sidetracked by other tasks because they are easier or more appealing. Sure, maybe Lesson 8 of your course material seems more interesting than Lesson 5, but you should work on the top priority item—Lesson 5—and continue working on it until completion. When you complete a task, send it on its way. Then check your priorities, and move to the next item. Time management consists of simply organizing yourself to make the best use of the time available.

Everyone has the same amount of time available. What you do with that time is up to you. Some people, through successful time management principles, make the most of their lives and create greater personal satisfaction for themselves and those around them. So, give a few of these time management ideas a try!

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Set a Schedule and Stick to It

You just learned about time management and the importance of scheduling. Creating a schedule for your studies is an important success strategy. You can use your own calendar (web or app-based calendars are great!) or create a weekly organizer, and fill in the days and dates.

Each week, write in all of your nonnegotiable commitments for the week, such as when you’re at your job or busy with your family. Then, find time slots that won’t be interrupted. Write STUDY TIME in big red letters across these times. Highlight them. Put stars by them. Do whatever it takes to keep these appointments. Remember to check your calendar often.

Here’s a sample weekly organizer that you can use as a guide.

In addition, you should study somewhere that is quiet, comfortable and well-lit. Do not allow yourself to be distracted, and schedule study times when you are alert and likely to be at your best. Lastly, your study sessions don’t have to be marathons, but you should make studying a part of your daily routine.

There you have it. You know all about success strategies and how these strategies can help you reach your goals. Remember to put what you’ve learned here to use. These success strategies have proven to be a great help to students—that’s why they’re called success strategies! So take advantage of them. Use them to help you succeed at being a good student, earning your certificate, starting a new job and doing well in your career!

Now that you can manage time, let’s look at motivation.

Step 5: Stay Motivated

As you learned earlier, you can set goals and establish a study schedule to aid in your success. It also helps to stay motivated. To keep your motivation up, study a little bit every day so that your momentum moves forward. In addition, completing the Practice Exercises will help you complete upcoming Quizzes. We want to help you succeed, and want to see you finish your course.

The most important factor in motivation is you! You are your own best motivator, so realize what motivates you to study. Perhaps your goal is to start a new, successful career, or start your own work-at-home business. It’s helpful to know what drives you, so you can determine how to get there.

Set smaller goals (daily, weekly and/or monthly) that can help you reach your larger goals. If you want to run a marathon, you don’t decide one day to run 26 miles. Instead, you set smaller, short-term goals that will help you run a marathon. You run a few miles each week and continue to add miles as you train. The same applies to your life—set smaller, short-term goals that will lead to your overall goal.

Online Learning

Build on what you are learning. Go to http://westonvideos.screencasthost.com and select Health Care. Locate Setting Goals to watch the video.

Another factor in motivation is procrastinating. Avoid procrastination! Keep going forward and completing each lesson, Practice Exercise and Quiz as you reach it. Each small goal will help you complete your larger goal—starting your new career. When you finish one lesson, preview the lesson objectives for the next lesson or begin reading your next lesson to keep up your momentum.

Sometimes it helps to talk with a mentor or a friend. A third person can support your goals, cheer for your progress and encourage you to do more. Remember, your instructors are available and are always happy to help!

Let’s take a tour of a typical medical office to meet some healthcare professionals.

Step 6: Teamwork in the Healthcare Profession

Before looking into the healthcare team, let’s take a tour of a typical medical office to meet some healthcare professionals.

Betsy made an appointment to take her two-year-old son to the doctor for a congested, ongoing cough. Betsy and her son, Gavin, arrive 10 minutes early for their appointment and check in at the front desk. Andrew, the medical office manager, greets Betsy. He updates Betsy’s contact and insurance information in the computer system, collects her copayment for the visit and asks her to complete a questionnaire regarding today’s visit. Betsy completes the form and then has a seat in the waiting area. Soon Jenni, the office’s medical assistant, calls Gavin’s name and asks them both to follow her. Jenni leads Betsy and Gavin into a room, and then Jenni takes Gavin’s temperature, pulse and blood pressure. She enters this information into her tablet and tells Betsy that Dr. Campbell, the physician, will be here in a few minutes.

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Medical offices are a team effort—all want to ensure you get the health care you need.
Soon you’ll be part of this exciting team!

Soon Dr. Campbell comes into the room and has a seat. He asks Betsy questions about Gavin’s cough and other health-related questions. Dr. Campbell listens to Gavin’s chest and takes a look at his throat, nose and ears. Dr. Campbell believes Gavin has bronchitis and prepares a prescription for Gavin. Dr. Campbell walks Gavin and Betsy back to the front desk, and Betsy provides her pharmacy information so that the Andrew can send Gavin’s prescription electronically. Betsy makes a follow-up appointment for Gavin, and then heads home.

Now that you’ve toured a typical medical office, let’s identify some of the key players in the healthcare profession and elaborate on what they do. In most professions, success comes from a team of people working together to accomplish goals. In medicine, physicians certainly cannot perform their jobs alone. Many people work hard, some behind the scenes, others more visibly, to ensure that our healthcare system runs properly. When you go to see the doctor, you don’t just see the doctor. You might see a number of professionals, including a receptionist or an office manager. Throughout a visit, a doctor may talk to several of the staff; all of these people are essential members of the medical care team.

Before moving on, let’s discuss the difference between inpatient and outpatient settings. An inpatient setting is a facility, other than psychiatric, that providers diagnostic, therapeutic (both surgical and non-surgical) and rehabilitation services by or under the supervision of physicians to patients admitted for a variety of medical conditions. Meanwhile, an outpatient setting may be a provider’s office, urgent care center, emergency department or an outpatient surgical facility.

Physicians

A person qualified to practice medicine is known as a physician. Also referred to as doctors or providers, physicians are the most prominent members of the medical care team. They perform life-saving procedures. They cure the sick and help heal wounds. Becoming a doctor of medicine is one of the most challenging career paths a person can choose. Not only do physicians earn four-year college degrees, but they also must complete medical school and one or more residency assignments. During residency, 85- to 100-hour work weeks are common. Because of this huge commitment, doctors deservedly receive much of the attention in the medical field.

Physicians determine what’s wrong with the patient or what’s causing the patient’s complaint. They prescribe drugs to alleviate symptoms, treat conditions and ease pain. They rely on their training to make quality, accurate decisions. However, as good as physicians are, their staff ultimately supports them as they provide quality treatment. Nurses are one essential part of the medical staff.

Nurses

As professionals who perform a variety of tasks in the medical world, nurses often must follow through with treatments physicians prescribe. Nurses can give injections and check a patient’s vital signs, as well as assist in surgery. It’s also true that nurses must often do the thankless jobs—cleaning up exam rooms and organizing supplies.

Without nurses, the number of patients a doctor sees in a day would drop dramatically. Nurses allow doctors to see more patients and focus on those patients who require the most care.

Online Learning

According to the American Association of Colleges of Nursing, “The U.S. is projected to experience a shortage of Registered Nurses (RNs) that is expected to intensify as Baby Boomer age and the need for health care grows.” Learn more about this topic at http://www.aacn.nche.edu/media-relations/fact-sheets/nursing-shortage.

Nurse’s and Physician Assistants

Two other categories of personnel in the medical field are nurse’s and physician assistants. Nurse’s assistants, or nursing aides, help nurses with daily duties, such as paperwork, general organization and taking a patient’s temperature, weight and blood pressure. Some nurse’s assistants also talk to patients and make sure they’re comfortable.

Perhaps you’ve seen a physician assistant instead of a doctor during an appointment.

Physician assistants (PAs) are normally under the supervision of a doctor and can perform some of the same functions as a doctor. PA duties might include stitching up a cut, taking a patient history and even performing lab work.

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Emergency Personnel

Emergency personnel are a group of professionals with the sole responsibility of providing immediate medical assistance and transporting the patient to the hospital for treatment. When someone is hurt and needs an ambulance, these people respond. Police officers, firefighters and other rescue professionals all have some level of medical training.

You have probably heard of emergency medical technicians (EMTs) and paramedics. EMTs take classes that enable them to stabilize patients who have a wide variety of emergency medical conditions. They are often members of ambulance crews and volunteer fire-fighting organizations. Paramedics have more training than EMTs. Paramedics are not only able to stabilize patients, but they can also begin treatments to cure patients, such as administering medication.

Support Staff

Physicians and nurses rely heavily on support staff to keep a medical office or clinic running smoothly. As you might guess, each of these positions plays an important role in the medical world.

Office Professionals

Office professionals include office managers and receptionists. Without this staff, many medical offices would grind to a halt! These people organize schedules, record appointments and answer patient questions. Office staff members have terrific communication and organization skills. They also must make a good first impression. The office manager may be the first person a patient sees upon entering a medical office, and the manager’s attitude can mean the difference between a pleasant visit and a nightmare for the patient.

Medical Assistant

Medical assistants are not physician’s assistants. As you recall, a physician’s assistant works directly under the supervision of a physician to examine, diagnose and treat patients. A medical assistant performs two different types of duties: administrative and clinical.

A medical assistant may answer phones, greet patients, schedule appointments, call for laboratory services, arrange hospital admissions, handle medical records and manage bookkeeping services.

Medical assistants in different states are allowed to perform some kinds of clinical tasks, as well. Typically, they may take a patient’s blood pressure and weight, record a medical history and prepare patients for the physician’s exam. They may directly assist the physician during the examination, explain a treatment procedure or instruct a patient about medication or special diets. Some medical assistants draw blood, collect and prepare other laboratory specimens, prepare patients for x-rays, change dressings, sterilize equipment and remove sutures.

Health Services Manager

A health services manager manages the services a healthcare facility provides, and might work for a group of physicians who have offices in several locations. Health services managers may be in charge of an outpatient service within a larger healthcare facility. Today, many healthcare providers form arrangements to offer a full set of health services under one roof, which requires a different kind of management than found in a large specialty practice. Also, preventing health problems is becoming more important, and this focus on prevention changes the role of healthcare providers as well as the management of healthcare services. So, as you can see, the potential roles of health services managers are very diverse!

Patient Care Technician

Patient care involves caring for the physically and mentally ill, as well as injured or disabled individuals and those in hospitals, nursing homes and mental healthcare facilities. Patient care technicians (PCTs) assist patients with eating, dressing, bathing, skin care and walking. They also turn, reposition and transfer patients between beds and wheelchairs. Home care aides are PCTs who visit clients’ homes to assist them with activities they can no longer perform alone. A PCT may help these patients with personal needs like grooming and eating, or with household tasks like cleaning and shopping.

Most importantly, patient care technicians monitor patients’ physical, mental and emotional needs. PCTs are care givers, so they are extremely valuable in the healthcare field; they are truly on the front lines of patient care.

Patient care technicians may complete specialized training either on the job or through classes and self-study courses. In addition, certain specialties require certifications in psychiatrics, mental health, geriatrics or home care.

Pharmacy Technician

Pharmacy is a science—the science of preparing and dispensing medications and information about medications. Pharmacists are professionals who perform these services. They ensure that people receive the proper medications for their health problems, and they provide information about these medications.

The pharmacy staff prepares medications ordered by the physician.

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Today, pharmacy is an important part of the total healthcare process, although pharmacists are not physicians. In the United States, physicians may provide samples of medications, but they don’t fill ongoing prescriptions for their patients. Similarly, pharmacists don’t diagnose diseases or prescribe medications—that is the physician’s role. Note that pharmacy professionals aren’t pharmacologists.

Pharmacologists research drugs and the ways drugs act in the human body. They also develop new drugs and demonstrate that these drugs are safe and effective for patients. Pharmacy professionals improve the quality of life for patients because the medications they provide help cure and prevent disease. Pharmacy professionals also put a human face on health care. Patients may not see their physicians for longer than ten minutes at a typical visit. However, at the pharmacy, patients can ask questions and receive answers that are specific to their own situations.

The pharmacy technician is one of the most valuable resources in the pharmacy profession. Demands in the pharmacy profession are growing as the population ages and faces increasing health problems. Pharmaceutical companies must continue to develop, test and produce new and improved drugs to treat these health issues. The number of pharmacists is also increasing, but the number of prescriptions that they must fill is increasing far faster! Computerized systems may help pharmacists handle part of the workload, but computers cannot do everything. Humans are still better at performing many tasks, which is why the pharmacy technician is an increasingly important professional in the healthcare field.

Medical Transcriptionists and Editors

At times, services provided by the physician are documented using dictation. After the service, the provider notes what happened during the encounter, usually using a recording device. That recording is called a dictation. That dictation then goes to a medical transcriptionist who listens to the doctor’s dictation and types what she hears. This is then added to the patient’s medical record. By using transcriptionists, doctors save time by speaking their notes. Some medical transcriptionists also serve as medical editors, who listen to the doctors’ spoken notes while editing rough reports that a speech recognition program produced based on the doctors’ dictation.

Medical Coding Specialists

Medical coding specialists assign medical codes to the information obtained from a patient’s visit to a medical facility. Each patient’s diagnosis, treatment and tests must be coded. The medical coding specialist gets the medical report that the physician dictated and the transcriptionist created. This healthcare professional examines the diagnosis and the treatment performed and assigns codes to each one. Coding requires the medical coding specialist to look up the information in a reference book and find the right set of numeric or alphanumeric codes that describes exactly what occurred during the patient’s visit.

Medical Billing Specialists

Medical billing specialists are a perfect example of how interrelated one job is to the next in a medical office. Remember, medical coding specialists assign appropriate codes describing what occurs during a patient’s medical visit, while medical billing specialists use the codes that a medical coder assigns to complete the insurance forms. These forms are necessary to collect payment from the insurance companies. Billing specialists know that the provider doesn’t get paid unless the form is completed and filed correctly.

Electronic Medical Records Specialist

An electronic medical records (EMR) specialist is trained to organize and manage patient health data in digital and hard-copy formats, ensuring the quality, accuracy, accessibility and security of this critical documentation. This healthcare professional must be able to confidently and confidentially discuss patient information with doctors, insurance personnel, healthcare administrators and other professionals, keeping a sharp eye on details and potential discrepancies in the records.

The EMR specialist may input medical reports from physical charts into electronic records on secure computer databases. The information may be typed or scanned into the patient’s medical record. Sometimes, this healthcare professional may perform quality checks. They’ll review the patient’s chart to verify the information was entered correctly. Finally, an electronic records specialist may run reports for security purposes, as well as checking quality standards. This may include checking who is accessing information, how long records are being reviewed and from which computer terminal.

Teamwork in health care

Step 7: Healthcare Professionals

Now that you know a bit about team players involved in healthcare, let’s build on that knowledge. You’ll take a look at different healthcare professionals, following them through a portion of a day so that you can get an idea as to the environments they work in and the tasks they must complete. Keep in mind these are very general examples.

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Medical Assistant

Holly is a medical assistant for a family medical practice with two doctors, Carla Matthews and Summer Gray. Holly arrives at work and sees the office manager, Maggie, pulling today’s charts for the scheduled patients. Maggie is generally the first person to greet patients, but if she is out sick, Holly’s administrative skills allow her to fulfill Maggie’s duties. Holly helps Maggie work through the charts to ensure that the appropriate lab and x-ray reports are there as well.

Maggie also asks Holly to perform the monthly audit of expiration dates on pharmaceutical samples over the course of the week. Holly knows how important it is to monitor these drugs. Out-of-date drugs can chemically change or lose their beneficial effects.

By this time, several patients have arrived and checked in with Maggie. Holly shows each patient to an examination room when the doctor is ready. Meanwhile, Maggie informs Holly that one of Dr. Matthews’ patients, Jill, is on her way to the office with possible strep throat.

Holly knows that she will need to get Jill’s vital signs upon arrival and prepare a room for an exam of Jill’s head, ears, neck, nose and throat. She also anticipates that Dr. Matthews will ask her to perform a strep culture of Jill’s throat. Holly prepares the exam room by setting out the otoscope, tongue blade and cotton applicators.

When Jill arrives, Holly leads her to the exam room and takes her vital signs. She immediately notes that Jill’s oral temperature is elevated at 100.2 °F. Her blood pressure is ١٠٢/٧٠, her pulse is 72 and her respirations are 20. Next, Holly asks Jill about her symptoms. Jill complains of a sore throat as well as a runny nose, left earache and cough productive of white mucus. Holly knows that Dr. Matthews will also listen to Jill’s lung sounds because of her cough, so she gives Jill a gown and asks her to remove the clothing on her upper body so her breath sounds will be clear.

Holly records these findings in Jill’s chart, and then notifies Dr. Matthews that her patient is ready for her exam. Dr. Matthews emerges from the exam room and asks Holly to perform a throat culture on Jill. She wants Holly to do a rapid screen so that she will know the results immediately and can prescribe the appropriate medication for her, if necessary. A rapid screen is the test for strep throat that Holly can perform in the office while the patient is there.

Holly gathers the rapid screen test kit and re-enters the exam room. Holly explains what she will do, puts on gloves and asks Jill to open her mouth. She places a tongue blade on Jill’s tongue. At the same time, she uses a sterile, cotton-tipped applicator in her other hand to swab Jill’s throat, being careful to include both sides and the center of her throat. Holly then swabs the material onto the test kit and returns it to the lab to interpret the results. She tells Jill that she may get dressed while she waits for the results.

In the lab, Holly informs Dr. Matthews that the results are negative; Jill does not have a strep infection in her throat. She records this result on a lab sheet to put into Jill’s chart. Dr. Matthews returns to the exam room to diagnose Jill with a common viral upper respiratory infection. She instructs Jill to use salt water rinses and acetaminophen for her low-grade fever and discomfort; she prescribes an over-the-counter medication to help with her runny nose. She instructs Jill to call if her temperature goes higher than 102 °F or if she does not feel better in five days. After the patient leaves, Holly hears Dr. Matthews dictating a report of the encounter.

Patient Care Technician

Paul is a patient care technician who has worked with elderly patients for the past 20 years. Paul works in a long-term care facility and performs many different tasks. He realizes the importance of setting priorities each day. Sometimes, he has to decide which tasks are most important.

Paul cares for six residents. He spends time visiting with them as he takes their vital signs, charts their food intake, and helps them with grooming and personal hygiene. Paul also assists with the facility’s animal therapy program, which is one of his favorite duties at work. A local organization brings dogs to visit with patients as part of this program. These are not ordinary dogs—they are certified therapy dogs, and have passed behavioral evaluations and a training program.

Paul enjoys seeing his residents brighten and relax when they are around the dogs, but his duties extend further. He transfers residents to the cafeteria, the recreation room or wherever else they need to go. Paul must know the correct procedure for helping each resident with mobility issues—some use canes or walkers and others use wheelchairs.

Paul can also assist residents with feeding and bathing. Paul’s resident, Isabel, needs help with personal hygiene—she likes to do her hair and put on a little makeup each morning, but her hands shake so much that she can’t manage it alone. Paul assists her with cleaning and grooming after he has charted her vital signs and food intake.

Paul’s next stop is with his favorite resident, Jane. She reminds him so much of his grandmother; she enjoys telling stories about her girlhood during the Great Depression. Today, Paul notices that Jane seems lonely and wants to talk. Paul only has a few minutes, but he knows that even ten minutes will make a big difference to Jane.

Communication is an important skill for the patient care technician.

In addition to these duties, Paul also performs certain daily tasks. He checks residents’ vital signs and informs the charge nurse of anything unusual. He assists residents who need help with their medications and visits with others.

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Pharmacy Technician

Danielle works in a pharmacy that is part of a retail store. She arrives at the pharmacy at 8:45 a.m. to start work at 9:00 a.m. sharp. Danielle handles the computer’s interactive voice response (IVR) system. Patients call the pharmacy with refill requests. The computer software lines up the calls in the pharmacy’s order queue, and Danielle begins the process. Today, 45 patients have called to request refills. Some days, only 20 patients call. Other days, more than 60 patients call!

Danielle downloads all of the calls and then prepares to fill the prescriptions. The IVR system produces paperwork for each prescription, so she puts this paper into a bag. She then goes to the medication storage shelves and removes the proper medications. Danielle counts the pills and puts them into vials. She puts labels on the vials, along with other special instructions.

The labels may specify “take with meals,” “for use in eyes only” or other specific details. Danielle fills each prescription and then leaves it on the counter. Ray, the pharmacist, knows to double-check the orders that are on the counter. Danielle does this for every drug refill call that the pharmacy receives. Then, she goes to the computer. Doctors submit prescriptions electronically. Danielle fills those prescriptions and leaves them for Ray, too.

So far, it has been a slow morning. No patients were waiting for the pharmacy to open. However, a customer comes to the window when Danielle is halfway through her morning prescriptions. Terri, the customer, had surgery on her hand last week and wants a refill for her painkiller prescription. Danielle checks the prescription; it specifies “no refills.” Danielle politely tells Terri that she needs the physician’s approval before she can refill the prescription. Terri asks to see Danielle’s boss for further information, so Ray comes to talk to Terri.

Danielle goes back to her other prescriptions while Ray confirms to Terri that the pharmacy cannot refill the prescription. He offers to call Terri’s physician to request a refill. Terri is grateful for Ray’s offer, and confirms that he may call the physician.

Danielle finishes filling the prescriptions, and then takes a half-hour lunch break. When she returns to work, she accepts the pharmacy’s drug order for that day. She removes the drugs from the shipping boxes and puts identification stickers on them. Then, she puts each drug onto the shelves in the proper locations.

Finally, Danielle’s six-hour shift is nearly finished. For the last hour, she completes any tasks that still remain. Some days, she submits refill requests to physicians. Other times, she pulls expired drugs from their shelves. She checks the over-the-counter diabetic supplies that the store sells, and orders any supplies that are running low. She even takes out the trash and boxes overstock items to return. In addition, she always stops to help customers who come in for prescriptions.

Medical Transcriptionist/Editor

Taylor is the medical transcriptionist and editor for Weston Medical Clinic and has worked as a medical transcriptionist for about 10 years. Before Weston, she worked with a transcription company that had several doctor’s offices and medical facilities in different parts of the country. Taylor has seen the change in the medical transcription field and has moved from transcribing audio tapes from offices in her area to transcribing digital sound files for facilities in other states. Now she works from home as a medical transcriptionist and editor for Weston Medical Clinic. Let’s take a look at a typical day for Taylor.

Taylor wakes up and heads downstairs to her home office by 8 a.m. Taylor logs onto the shared drive to which all the transcriptionists have access. Every doctor at the clinic has a folder on the shared drive. Each physician carries around digital hand-held devices and dictates information directly into it. These sound files are then loaded onto the shared drive and saved into the corresponding doctor’s folders. Taylor opens up one of the sound files that she needs to transcribe. She uses a special program that is connected to the patients’ electronic records. After Taylor is finished typing it, she saves it to the patient’s chart on the computer and moves the sound file into a folder for the finished reports. Once the transcribed report is saved in the patient’s chart, it goes back to the physician for a signature. The physician opens up the report and signs it electronically. Then Taylor is ready to start another report!

Some of Taylor’s doctors use speech recognition technology (SRT) to transcribe reports. The SRT program takes the physician’s dictation and creates a rough report. Taylor listens to the dictation and follows along with the report to make sure it’s accurate. Taylor edits as necessary and puts the report in the correct format.

Taylor appreciates this technology because she doesn’t have to type all of the physician’s notes, and it has created a new role for transcriptionists. Most of the time, Taylor only has to alter portions of the report as she carefully edits it. Taylor also appreciates the time the technology saves; she can work from home because she can access the files and programs she needs electronically!

Medical Coding Specialist

Marge is the medical coding specialist for Weston Medical Clinic. Like Taylor, she works at home. After getting her children off to school and refreshing her cup of coffee, Marge heads to her home office, ready to start her day! At Weston Medical Clinic, the coding specialist works on charts from the pervious business day. For instance, the medical coding specialist works on Tuesday’s medical records on Wednesday, Wednesday’s medical records on Thursday and so on.

Marge logs onto her computer with her password and downloads the report that Taylor created and saved to the electronic record. Marge spends most of the remainder of the day reading reports to assign the correct diagnosis and procedure codes. After assigning the codes to a record, Marge saves the electronic record and moves to the next record.

Just before her children arrive home from school, Marge receives a phone call from Joann, Weston Medical Clinic’s billing specialist. Joann has received a denial for a claim and asks Marge to pull up the record to check for accurate coding. Marge reviews the record and notes the numbers for the code were transposed. She provides the correct code for Joann to resubmit the claim.

By the end of the day, Marge has completed the coding for all of the services performed at Weston Medical Clinic the previous day.

Medical Billing Specialist

Joann is the billing specialist for Weston Medical Clinic. She usually starts the day by going through the claims that are still outstanding, which are bills that haven’t been paid yet. For this clinic, most of these outstanding claims are waiting for insurance payments. The others are due either from patients who don’t have insurance or from patients who need to pay the remaining portions of the bills that their insurance policies did not cover.

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A few of the insurance claims are late in being paid, so Joann starts calling the individual insurance companies, trying to track down each claim. It takes two hours for her to work through 10 claims. This type of follow-up is very important for the clinic. It prevents any claim from “slipping through the cracks” of the insurance world. After getting a better idea of when to expect payment for the 10 claims, Joann works on the individual claims or those that have a balance due from the patient.

Joann checks the individual claims for the time of notification to determine how long it has been since each person received the bill. She marks those that are 60 or more days past due. These people will soon receive another reminder requesting payment.

Finally, Joann is ready to work on creating claims for the services that have been coded by Marge. Joann checks the patient information to make sure that the patient included all necessary information, including the name, address, insurance company and policy number. After making sure all the information is correct, she transfers the codes to an insurance claim form. By 4:30 p.m., Joann has processed the claims. They will be submitted to their respective insurance companies, and the clinic waits for payment.

You now have an idea of what the healthcare support staff does every day. Let’s continue by studying some general responsibilities.

Step 8: Responsibilities

You just read about the work of medical coders, billers, transcriptionists and editors. Keep in mind that the support staff may perform any or all of the same tasks as these professionals. Healthcare support staff have five basic responsibilities:

1. Transcribe/Edit Dictation.

Create reports by transcribing digital voice files into a medical record, or by editing text that has been created by computer software systems.

2. Code Records.

Read the medical record to determine the diagnoses and procedures that apply. Reference manuals are used to assign codes to represent the diagnoses and procedures.

3. Complete and Submit Insurance Claim Forms.

Complete and submit the appropriate insurance claim form.

4. Follow Up on Claims and Bills.

Follow up with the insurance company regarding the claim and/or follow up with patients to secure payment.

5. Secondary Insurance Claims and Patient Billing.

Submit a bill to the secondary carrier. If the patient does not have secondary insurance, then the patient may be responsible for paying whatever remains after the primary carrier has paid.

Online Learning

Pick one of the healthcare positions mentioned in this lesson. Search online to find more information about that position. What did you like and dislike? Think about the position’s job requirements, daily tasks, salary rates, etc.

Step 9: Practice Exercise 1-1

Select the best answer from the choices provided.

1. The _____ may be the first person in the doctor’s office to see a patient.

a. office manager

b. doctor

c. EMR specialist

d. medical coding specialist

2. The _____ can perform both administrative and clinical duties.

a. medical assistant

b. patient care technician

c. medical transcriptionist

d. health services manager

3. The _____ assists patients with transferring between the bed and wheelchair.

a. nurse

b. physician

c. medical transcriptionist

d. patient care technician

Answer as directed.

4. Describe the five basic responsibilities of the healthcare support staff.

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Step 10: Review Practice Exercise 1-1

Check your answers with the Answer Key at the back of this book. Correct any mistakes you may have made.

Step 11: Personal Qualities

If you think about it, there are a large number of potential clients available in most towns. Even small towns usually have one or two practices and a hospital. Many times qualified help is hard to find, and because you have a skill that is in great demand, you have the opportunity to make good money. Though salaries vary depending on experience, the number of hours worked and location, you’ll be pleased to discover the amount of money you can earn as a healthcare professional. Remember that as your experience builds, you can add to your earnings while being a vital part of a medical team and doing work that helps people.

The main thing to remember when you approach a potential client or employer is that you are the best choice for the job. Your competence means money to your employers! You should remember and practice three qualities: professionalism, presentation and adaptability.

Professionalism

Professionalism is the conduct, aim or qualities that characterize a profession or professional person. As with any business, the image you project is important. You must be professional. Professionalism includes how you dress, talk and interact with your clients. When you have an initial meeting with potential clients, your level of professionalism will affect their impression of you.

When you select what to wear, be conservative but not bland. Your attire should be clean, wrinkle-free and professional. Try to choose something you feel comfortable wearing. If you are comfortable, you will be able to concentrate on other important things, such as your presentation and answering any questions your potential client may have. An uncomfortable outfit, whether in style, color or both, will distract you.

Let’s look at the following example to see how professionalism affects our choices.

Jane entered the Haber Dash Men’s Store to exchange a tie for her husband. As she approached the counter, she saw that two clerks were at either end. She noticed that one clerk wore a t-shirt and torn jeans and had a few visible piercings. The other clerk was dressed conservatively in black pants, a starched white shirt and a snazzy bow tie. In a split second, she decided who looked the most helpful. She thought the conservatively dressed clerk would be more sympathetic to her tie dilemma, so she approached him for assistance.

Has this ever happened to you? Perhaps if Jane wanted advice on which CD to buy for her son, the other clerk would have appeared more competent. While it may not be fair, Jane made a judgment based on how each employee looked. Of course, no two people look alike, but there are certain factors of appearance that are important in the work setting. This is especially true for a professional healthcare worker.

Another facet of professionalism is delivering what you promise. You’ve probably heard the saying, “Five minutes early is 10 minutes late.” Basically, this means if you have a meeting at 10 a.m., be 15 minutes early. Never be late, especially for a first-time interview. Such promptness shows you are responsible and considerate. If your client is a little late, be understanding. Just make sure you aren’t the tardy one. When you are asked for work samples, be prepared. Explain what you know and how you gained your knowledge. If you ever are asked to complete a test task, do so promptly.

Online Learning

Research “healthcare professionalism” and you’ll find a variety of definition, qualities and examples. Think back on your own experience, both the positive and negative aspects of professionalism you’ve encountered.

Presentation

Presentation is the act of bringing or introducing something into the presence of someone else. Often your initial presentation will decide whether you gain a client or employer. In addition to being on time and dressed properly for the meeting, your presentation can go a long way in influencing your client-to-be—both positively and negatively.

Be sure to present a confident image. Your attitude should say, “I know what I’m doing” without being arrogant or condescending. Remember, this is the client’s money you’re talking about. Confidence is a must!

Online Learning

Build on what you are learning. Go to http://westonvideos.screencasthost.com and select Health Care. Locate Presentation to watch the video.

Adaptability

Adaptability is the ability to be modified or changed. To be successful, you must be able to adapt for each client. Some people want tasks done a certain way. Others may have exactly the opposite requirements. Codes are updated annually. Insurance regulations change. Forms are altered. If you get too set in your ways, you might lose clients who require slightly different approaches.

Step 12: Character Traits

What makes a top-notch healthcare professional? Let’s examine some of the most important character traits. You’ll be able to boast about these traits by the end of your course!

Character traits are important to the healthcare profession.

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Curiosity and Drive

You need to have a true interest in the healthcare field. You demonstrated an interest by enrolling in this course! This includes the constant desire to follow the ever-changing face of medicine. As you progress in your field, be willing to open your mind to new information to learn new skills and change your life.

Warmth and Confidence

It’s important to appreciate the satisfaction of caring for others. You may interact with other people, such as coworkers, doctors and patients, and you can do so in a courteous, pleasant manner. Showing warmth and compassion will put patients at ease. As you begin your career, be confident in your abilities and understanding of the information you’re explaining.

Organizational and Professional Skills

A successful healthcare professional is a multi-tasker because she handles several responsibilities at once. Remember to make lists of things to do so you don’t forget any of your tasks for the day. As you start working, you’ll learn to keep charts and other paperwork organized so that you can find what you need at a moment’s notice. You’ll also realize that it’s important to keep your work area clean and tidy so there’s room to work and you don’t lose things. It’s also important to be able to prioritize, or decide which duties are most urgent. “Should I code Mrs. Smith’s record first, or should I follow up on insurance payments?”

As you can see, it’s important to keep organized and to prioritize.

Step 13: Practice Exercise 1-2

Determine the term(s) to complete each sentence.

1. A healthcare professional should exhibit three personal qualities: _____, _____ and _____.

2. Presenting a(n) _____ image is important.

3. Handling several responsibilities at once is termed _____.

4. _____ is the ability to be modified or changed.

Answer as directed.

5. Explain the most important character traits of a successful healthcare professional.

Step 14: Review Practice Exercise 1-2

Check your answers with the Answer Key at the back of this book. Correct any mistakes you may have made.

Step 15: Summary

Healthcare support staff are an important part of any medical setting because they are able to perform tasks such as coding, billing, transcription and editing. This lesson gave you a firm understanding as to what members of the healthcare team do. You’ll work with physicians, nurses, office managers and others to contribute to the best possible patient care.

We also discussed a few important points for you to remember as you move toward your new career. You learned the importance of professionalism, presentation and adaptability. Lastly, this lesson highlighted character traits of a successful healthcare professional.

As you continue with this course, you’ll see in greater detail just how important your role is to those who work in and rely on medical facilities. This career is in demand! By choosing this course, you have started on an exciting path toward success.

Great job completing Lesson 1! You’re one lesson closer to your new career. Complete Quiz 1 and then continue to Lesson 2 to learn more about medical billing.

Step 16: Quiz 1

Once you’ve mastered the course content, locate this Quiz in your Online Course or your Assignment Pack. Read and follow the Quiz instructions carefully.

Endnotes

1 “TED: The Economics Daily.” United States Department of Labor, 28 February 2012. Accessed 1 May 2017. Web.

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*With experience, all wage data is based on figures from the U.S Dept. of Labor’s BLS website, professional associations and/or 3rd party resources website. Figures for this occupation were obtained at http://www.bls.gov/oes/current/oes292071.htm. [May 15, 2018]. For more information, click here.