CCMA (NHA) key terms

Practices that reduce the number and spread of microorganisms, such as hand hygiene, cleaning surfaces, and wearing gloves. It keeps pathogens from moving between patients, staff, and equipment but does not make an item sterile.

Also called sterile technique, this is the set of practices that keeps objects and areas free of all microorganisms, including spores. It is used for procedures such as catheter insertion, surgery, and dressing changes on open wounds.

A model describing six linked steps needed for an infection to spread: infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host. Breaking any link helps stop transmission.

Barriers worn to protect the wearer and patients from contact with infectious material, including gloves, gowns, masks, respirators, and eye protection. The type chosen depends on the task and the exposure expected.

Microorganisms carried in blood and body fluids that can cause disease when they enter the body, such as hepatitis B, hepatitis C, and HIV. Standard precautions and safe needle handling reduce the risk of exposure.

A process that destroys all microorganisms, including bacterial spores, on an item. In ambulatory care an autoclave uses pressurized steam, and sterilized items must be monitored to confirm the process worked.

The standard reference posture: standing upright, facing forward, arms at the sides with palms forward, and feet flat. Directions such as anterior, posterior, medial, and lateral are described as if the patient were in this position.

The body's tendency to keep internal conditions such as temperature, pH, blood glucose, and fluid balance within a narrow, stable range despite outside changes. Feedback loops constantly adjust these values.

Imaginary flat surfaces used to describe body sections: the sagittal plane divides left and right, the frontal or coronal plane divides front and back, and the transverse plane divides top and bottom.

The enclosed spaces that hold internal organs. The dorsal cavity contains the cranial and spinal cavities; the ventral cavity contains the thoracic cavity with heart and lungs and the abdominopelvic cavity with digestive and reproductive organs.

The two phases of the cardiac cycle. Systole is the contraction that pushes blood out of the heart and produces the higher blood pressure number; diastole is the relaxation and filling phase that produces the lower number.

Routine measurements of body function: temperature, pulse, respirations, and blood pressure, often with pain level or oxygen saturation. They are compared with the patient's baseline and normal ranges to detect changes in condition.

The sounds heard through a stethoscope over the brachial artery as a blood pressure cuff deflates. The first clear tapping sound marks systolic pressure, and the point where the sounds disappear marks diastolic pressure.

Collecting blood from a vein, most often in the antecubital area, using a needle with a collection tube or syringe. Correct site selection, tourniquet time, and labeling affect specimen quality and patient safety.

The required sequence for filling blood collection tubes so additives from one tube do not contaminate another. A common sequence is blood cultures, light blue, red or gold, green, lavender, then gray.

Rupture of red blood cells so hemoglobin leaks into the plasma or serum, giving the sample a pink or red tinge. It can be caused by a small needle, excessive suction, shaking, or forcing blood through a needle.

Collecting a small blood sample by pricking the skin, usually the side of a fingertip or the heel in infants. It is used for tests such as glucose, hemoglobin, and newborn screening when venous blood is not needed.

Delivering medication deep into a muscle, such as the deltoid, vastus lateralis, or ventrogluteal site, where it is absorbed quickly. Needle length and gauge are chosen based on the site and the patient's size.

A way to confirm learning by asking the patient to explain or demonstrate the information in their own words. If they cannot, the educator reteaches the content instead of simply repeating it.

A written, individualized outline of the patient's goals, the interventions planned, and who is responsible for each step. It is updated as the patient's condition or needs change.

Sending a patient to another provider or specialist for care beyond the current practice's scope or expertise. It usually includes documentation of the reason, relevant records, and insurance authorization when required.

Approval obtained from an insurance plan before a service, medication, or procedure is provided. Without it the plan may deny payment, so staff verify requirements and document the approval number.

A person's ability to obtain, understand, and use health information to make decisions. Low health literacy is common, so instructions should use plain language, pictures, and confirmation of understanding.

A digital record of a patient's health history, visits, orders, results, and medications that can be shared among authorized providers. It replaces or supplements paper charts and supports billing and reporting.

A progress note format: Subjective for what the patient reports, Objective for exam findings and data, Assessment for the provider's impression or diagnosis, and Plan for tests, treatment, and follow-up.

The code set used to report diagnoses and the reasons for visits on claims and in the medical record. Accurate coding supports billing, quality reporting, and tracking of public health trends.

Current Procedural Terminology, a code set maintained by the American Medical Association that describes medical services and procedures for billing. Codes must match documented services, since errors can cause denials or fraud concerns.

A statement from the insurance plan showing what was billed, what the plan paid, and what the patient owes. It is not a bill, though it helps patients understand their balance.

A form or screen listing the diagnoses, services, and charges from a visit that is used to create the insurance claim. The provider completes it and billing staff check it against the documentation.

Fully concentrating on the speaker, noting words, tone, and body language, and giving feedback that shows understanding. It reduces misunderstandings and helps patients feel respected and heard.

Purposeful conversation that supports the patient's emotional and physical well-being using empathy, open questions, reflection, and respect for boundaries. It avoids judgment, false reassurance, and advice beyond one's role.

A structured handoff format: Situation, Background, Assessment, and Recommendation. It gives a concise, organized report so the next caregiver or provider can act quickly and safely.

The ability to recognize and respect patients' cultural values, beliefs, language, and health practices and to adapt care accordingly. It includes using interpreters and avoiding assumptions based on appearance or background.

A federal regulation that limits how covered entities may use and disclose protected health information. It requires safeguards, a notice of privacy practices, and patient authorization for most non-treatment disclosures.

Individually identifiable health data, such as name, date of birth, diagnosis, or account number, held or transmitted by a covered entity. It must be safeguarded and shared only as the law permits.

The HIPAA principle that only the least amount of protected health information needed for a task should be accessed or disclosed. It applies to routine uses and disclosures unless a specific exception applies.

A patient's voluntary agreement to a procedure after receiving information about its purpose, risks, benefits, and alternatives. It requires decision-making capacity and must be documented; staff often witness rather than obtain it.

The duties and procedures a medical assistant or other health professional may legally perform, defined by state law, licensure, and employer policy. Working outside it can lead to discipline and liability.

Failure to provide the level of care a reasonably prudent professional would give in similar circumstances, resulting in harm. It requires duty, breach, causation, and damages; malpractice is professional negligence.

A legal document stating a patient's wishes for future medical care, such as a living will or a durable power of attorney for health care. It is used when the patient cannot speak for themselves.