NCCT NCMA key terms

Practices that reduce the number and spread of microorganisms, such as hand hygiene, gloves, and routine cleaning of surfaces. It does not destroy all spores and is used in everyday patient care.

Techniques that keep an area or object completely free of all microorganisms, including spores. Used for sterile procedures such as dressing changes, catheter insertion, and injections.

Infection-control measures applied to every patient regardless of diagnosis, including hand hygiene, gloves, gowns, masks, and safe handling of sharps and body fluids.

Extra precautions used when a specific pathogen spreads by contact, droplet, or airborne routes. They add gowns, masks, respirators, or private rooms on top of standard precautions.

Barrier items worn to protect the worker and patient from exposure, including gloves, gowns, masks, respirators, and eye protection. Selection depends on the task and anticipated splash risk.

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

A work area treated as free of all microorganisms. Only sterile items may touch it, and anything that contacts a nonsterile surface is considered contaminated.

The method of putting on and removing sterile gloves without touching the outside of the gloves with bare hands, preserving sterility for procedures such as wound care.

Practices that prevent sharps injuries, including not recapping needles, using safety-engineered devices, and disposing of sharps immediately in approved puncture-resistant containers.

A written workplace program describing how bloodborne pathogen exposure is prevented and what to do after an exposure, including reporting, evaluation, and follow-up care.

The U.S. federal agency that sets and enforces workplace safety rules, including the bloodborne pathogens standard that governs exposure control in medical offices.

Measurements of temperature, pulse, respiration, blood pressure, and often pain or oxygen saturation. They establish a baseline and reveal changes in a patient's condition.

The force of blood against artery walls, recorded as systolic over diastolic pressure in millimeters of mercury. Measured with a cuff and stethoscope or an automated device.

The rhythmic expansion of an artery with each heartbeat, counted for rate, rhythm, and strength. Common sites include the radial, brachial, and carotid arteries.

The exchange of oxygen and carbon dioxide, assessed by counting breaths per minute and noting depth, rhythm, and effort without telling the patient you are counting.

A noninvasive method using a sensor on a finger or earlobe to estimate the percentage of hemoglobin saturated with oxygen, helping detect low blood oxygen.

A screening number calculated from height and weight that estimates whether a person's weight is in a healthy range. It does not measure body fat directly.

Objective measurements of the body such as height, weight, and head circumference, used to track growth and nutritional status and to calculate medication doses.

Recording of all fluids a patient takes in and puts out, used to assess hydration, kidney function, and response to treatment. Output includes urine, vomit, and drainage.

Physical, chemical, and microscopic testing of a urine sample to screen for infection, kidney disease, diabetes, and other conditions. Often performed in the office laboratory.

Obtaining and labeling body fluid or tissue samples for laboratory testing. Correct patient identification, container, timing, and labeling are essential to valid results.

A documented record of who collected, handled, and stored a specimen or sample at each step, ensuring legal integrity for drug testing and forensic purposes.

Puncturing a vein with a needle to draw blood or start an infusion. It requires site selection, aseptic technique, correct tube order, and proper labeling.

The sequence in which blood collection tubes are filled to prevent additive carryover between tubes. Following the correct order protects test accuracy and reduces contamination.

Collecting a small blood sample by pricking a fingertip or heel. Used for glucose checks, hemoglobin, and newborn screening when venous access is not needed.

A recording of the heart's electrical activity through electrodes placed on the skin. It helps detect arrhythmias, ischemia, and other cardiac conditions.

A portable device worn for 24 to 48 hours that continuously records the heart's electrical activity, capturing irregular rhythms that a brief office tracing might miss.

Giving a prescribed drug by the correct route, dose, time, and patient, with documentation. It requires verifying the order and checking for allergies and interactions.

A safety checklist confirming the right patient, drug, dose, route, time, and documentation before giving a medication, reducing preventable medication errors.

Delivering medication by injection or infusion rather than through the digestive tract. Routes include intradermal, subcutaneous, intramuscular, and intravenous.

Injecting medication into muscle tissue, commonly at the deltoid or ventrogluteal site. Needle length and gauge depend on the patient and the medication volume.

Injecting medication into the fatty layer beneath the skin, such as for insulin or heparin. Sites include the abdomen, thigh, and upper arm.

The legal and clinical documentation of a patient's care, including history, findings, orders, and treatments. It must be accurate, timely, and protected as confidential.

U.S. law that protects the privacy and security of health information and defines permitted uses and disclosures, plus patient rights over their records.

Individually identifiable health information held or shared by a covered entity. Its use and disclosure are restricted by federal privacy rules.

A patient's voluntary agreement to a procedure after receiving and understanding information about its purpose, risks, benefits, and alternatives. It is documented in the record.

A legal document stating a patient's wishes for care if they cannot speak for themselves, such as a living will or durable power of attorney for health care.

Managing the calendar of patient visits by type, duration, and provider availability to reduce waiting, avoid conflicts, and keep the office running efficiently.

Collecting and verifying a new or returning patient's demographic, insurance, and contact information to create or update the record and support billing.

Confirming a patient's coverage, benefits, and eligibility before care so the practice knows what will be paid and what the patient owes.

A fixed amount a patient pays at the time of a covered service, separate from deductible and coinsurance amounts. It is collected during check-in or check-out.

A statement from an insurer showing services billed, amounts allowed, amounts paid, and the patient's responsibility. It is not a bill.

A standardized code set describing medical services and procedures, used for billing and reimbursement and updated annually.

A standardized code set for diagnoses and health conditions, used to justify services, support billing, and track public health data.

Translating clinical documentation into standardized diagnosis and procedure codes so claims are accurate and payable, and so records support quality reporting.

A digital system storing a patient's clinical information across visits, supporting orders, results, prescribing, and communication among care team members.