NHA CCMA key terms

Practices that reduce the number and spread of microorganisms, such as hand hygiene, gloves, and surface disinfection. It differs from surgical asepsis because spores are not necessarily destroyed.

Technique that keeps objects and areas completely free of all microorganisms, including spores. Used for sterile dressing changes, urinary catheter insertion, and any procedure entering sterile body cavities.

Infection-control rules applied to every patient regardless of diagnosis. They cover hand hygiene, gloves, gowns, masks, eye protection, sharps handling, and safe disposal of contaminated items.

Personal protective equipment such as gloves, gowns, masks, and eye shields worn to block contact with blood, body fluids, and airborne particles. Selection depends on the task and expected exposure.

Extra precautions for infections spread by large respiratory droplets, such as influenza. They require a mask within a set distance of the patient, often about three feet, plus standard precautions.

Precautions for pathogens that stay suspended in air, such as tuberculosis and measles. They require a fit-tested N95 respirator and, when available, a negative-pressure room with the door closed.

Puncture-resistant, labeled, leakproof bin for used needles, lancets, and broken glass. It is filled only to the marked fill line and never overfilled or recapped by hand.

Accidental puncture of skin by a contaminated needle or sharp. The exposed worker washes the site, reports immediately, and follows post-exposure testing and prophylaxis protocols.

Model of six linked elements: infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host. Breaking any link stops transmission.

Lowering the number of germs on a surface or instrument by washing and scrubbing. It usually comes before disinfection or sterilization and does not destroy all organisms.

Using chemicals to kill most disease-causing organisms on surfaces or equipment. It does not reliably kill spores, so it is used for items that do not enter sterile tissue.

Process that destroys all microorganisms, including spores, on an item. Autoclaving with steam under pressure is common; items are then stored to stay sterile until use.

Work area treated as free of all microorganisms, created with a sterile drape and sterile supplies. Only sterile items touch it, and anything contacting a nonsterile surface is considered contaminated.

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

Noninvasive estimate of arterial oxygen saturation using a light sensor on a finger or earlobe. Poor circulation, nail polish, and motion can cause inaccurate readings.

A drop in blood pressure when a patient moves from lying to sitting or standing, causing dizziness. It is checked by measuring pressure and pulse in each position.

Choosing a cuff whose bladder length and width fit the patient's arm circumference. A cuff too small reads falsely high; one too large reads falsely low.

Puncturing a vein with a needle to collect blood or give fluids. The medical assistant selects the site, cleans the skin, anchors the vein, and applies pressure afterward.

Standard sequence for filling blood tubes to prevent additive carryover between tubes. It generally starts with blood culture and coagulation tubes and ends with additive tubes.

Breakdown of red blood cells that releases hemoglobin and colors the serum pink or red. It can result from rough handling, a small needle, or pulling too hard on the syringe.

Collection of a small blood sample by pricking the side of a fingertip or the heel of an infant. It is used for glucose checks and tests needing only a few drops.

Injection into the top layer of skin, usually on the inner forearm, using a short bevel needle at a shallow angle. It creates a small wheal and is used for allergy and TB skin tests.

Injection into fatty tissue beneath the skin, often the abdomen or thigh, using a short needle at a 45- to 90-degree angle. Insulin and heparin are common examples.

Injection deep into a muscle such as the deltoid or ventrogluteal site, using a longer needle at 90 degrees. Site choice depends on volume and patient age and size.

Injection technique in which skin is pulled aside before the needle goes in and released after withdrawal. It seals the track and prevents irritating medication from leaking back into tissue.

Comparing a patient's full medication list, including over-the-counter drugs and supplements, against current orders. It catches duplications, omissions, and interactions at transitions of care.

Checks performed before giving any drug, covering the right patient, drug, dose, route, and time, plus documentation and reason. Many settings add the right to refuse.

Unintended harmful response to a medication given at a normal dose. Signs may include rash, breathing trouble, or organ effects and are reported and documented promptly.

Severe, rapid allergic reaction with airway swelling, low blood pressure, hives, and breathing difficulty. It is a medical emergency treated with epinephrine and emergency services.

Device that sterilizes instruments with high-pressure steam. Items must be cleaned first, wrapped properly, and allowed to dry before storage to remain sterile.

Interference on an electrocardiogram tracing from movement, loose electrodes, or electrical sources. It can mimic arrhythmias, so the tracing is corrected and repeated.

Protected health information: any individually identifiable health data held or transmitted by a covered entity. Its use and disclosure are limited by federal privacy rules.

Federal rule governing how covered entities may use and disclose protected health information. It also grants patients rights to access, amend, and receive an accounting of disclosures.

Principle that only the least amount of protected health information needed for a purpose should be used, shared, or requested. It applies to routine disclosures and internal access.

Written patient authorization permitting disclosure of specified health information to a named person or organization. It states purpose, expiration, and the patient's right to revoke.

Patient's voluntary agreement to a procedure after receiving an explanation of risks, benefits, and alternatives. The provider obtains it; the assistant may witness and document the signature.

Legal document stating a patient's wishes for future medical care, such as a living will or durable power of attorney for health care. It guides decisions if the patient cannot speak.

Explanation of benefits: insurer statement showing services billed, amounts allowed, what the plan paid, and any patient responsibility. It is not a bill, though patients often confuse the two.

Fixed dollar amount a patient pays at the time of a covered service, such as a set fee per office visit. It differs from coinsurance, which is a percentage.

Share of covered costs the patient pays as a percentage after the deductible is met, while the plan pays the rest. For example, an 80/20 plan leaves the patient 20 percent.

Amount a patient must pay out of pocket for covered care before the insurance plan begins paying its share. Preventive services are sometimes exempt.

Standard paper claim form used to bill professional services to Medicare and many commercial insurers. It carries patient, provider, diagnosis, and procedure codes in designated fields.

Five-character code describing a medical service or procedure for billing purposes. Codes come from the current procedural terminology system and must match the documented work performed.

Code used to report a patient's diagnosis on claims and in records. It supports medical necessity for the services billed and must reflect the highest level of documented specificity.

Requirement that a service be reasonable and needed to diagnose or treat the patient's documented condition. Payer denial often results when diagnosis and procedure codes do not support each other.

An explanation of benefits goes to the patient summarizing processed claims, while a remittance advice goes to the provider with payment details and adjustment reasons. Both explain payer decisions.

Money owed to the practice for services already delivered. Aging reports sort balances by how long they have been outstanding so staff can follow up on delinquent claims.

Template defining appointment slots by provider, visit type, and length. It controls how bookings are made so urgent, follow-up, and new-patient visits get appropriate time.

Patient who misses a scheduled appointment without canceling in advance. Practices track these rates, use reminders, and may apply documented office policies to reduce lost revenue.

Sorting patients by urgency to decide who needs care first. In a medical office it guides same-day scheduling and whether a patient should be sent to urgent or emergency care.

Electronic health record: a digital, shared record of a patient's clinical history across visits and settings. It supports documentation, orders, results, and coordination among care team members.

Program of incentives requiring eligible providers to demonstrate meaningful use of certified electronic health records. It pushed adoption of e-prescribing, patient portals, and structured data exchange.