RMA key terms

Practices that reduce the number and spread of microorganisms in the healthcare setting, including hand hygiene, disinfection of surfaces, and careful handling of soiled linens. These techniques lower contamination risk but do not necessarily destroy bacterial spores.

Techniques that keep a work area and objects completely free of all microorganisms, including spores. Used for invasive procedures such as surgery, urinary catheter insertion, and dressing changes on open wounds.

Infection-control practices applied to every patient regardless of diagnosis, based on the assumption that all blood and body fluids are potentially infectious. They include hand hygiene, gloves, gowns, masks, eye protection, and safe sharps handling.

Barrier items worn to protect the medical assistant from exposure to infectious agents and hazardous materials, such as gloves, gowns, masks, protective eyewear, and face shields. The selection depends on the task and the exposure expected.

Puncture of a vein with a needle to withdraw blood or administer fluids. Most commonly performed in the antecubital area using a tourniquet, an evacuated tube system, or a butterfly needle.

The shallow triangular area on the anterior surface of the elbow that contains the median cubital, cephalic, and basilic veins. It is the preferred site for routine venipuncture because the veins are large and easy to access.

A constricting band applied above a venipuncture site to slow venous return so veins become more visible and firm. It should be released within about one minute to avoid hemoconcentration and inaccurate laboratory results.

Collection of a small blood sample by pricking the skin, usually the lateral side of a fingertip or the heel of an infant. Used for tests such as glucose and hemoglobin when venous blood is not required.

An instrument used to measure blood pressure, consisting of an inflatable cuff, a pressure gauge, and a deflation valve. It is used with a stethoscope to detect Korotkoff sounds over the brachial artery.

The series of sounds heard through a stethoscope over an artery as a blood pressure cuff deflates. The first clear sound indicates systolic pressure and the point where sound disappears indicates diastolic pressure.

A graphic recording of the heart's electrical activity obtained by placing electrodes on the chest and limbs. It is used to detect arrhythmias, ischemia, conduction abnormalities, and other cardiac conditions.

Delivery of medication deep into a muscle, commonly using the deltoid, vastus lateralis, or ventrogluteal site. Absorption is faster than with subcutaneous injection but slower than with intravenous administration.

A device that sterilizes instruments and supplies using high-pressure saturated steam at elevated temperature. Items must be cleaned and properly packaged first, and sterilization is verified with chemical indicators or spore testing.

A puncture-resistant, leak-proof, labeled container used to dispose of used needles, lancets, and other sharp items immediately after use. Proper use prevents needlestick injuries and exposure to bloodborne pathogens.

A fixed dollar amount a patient pays at the time of service as specified by the insurance plan. It is usually collected at check-in and is separate from deductible and coinsurance amounts.

The amount a patient must pay out of pocket for covered services before the insurance plan begins paying its share. Deductibles typically reset each calendar or plan year.

The percentage of covered charges the patient is responsible for after the deductible has been satisfied, for example 20 percent of the plan's allowed amount. It is calculated on the allowed charge, not the billed charge.

A statement from the insurance payer summarizing the services billed, the allowed amount, what the plan paid, and the patient's remaining financial responsibility. It is not a bill and is often confused with one.

The standard paper claim form used to bill Medicare and most other third-party payers for professional services. It contains patient, insured, provider, diagnosis, and procedure information in numbered fields.

A five-character numeric code from the Current Procedural Terminology system that describes a medical service or procedure for billing purposes. The code set is maintained by the AMA and updated annually.

The coding system used to report diagnoses and reasons for visits on claims and in the medical record. Codes are alphanumeric and should be selected at the highest level of specificity documented by the provider.

A financial report that groups unpaid patient and insurance balances by how long they have been outstanding, such as 0-30, 31-60, and 61-90 days. It guides collection follow-up and reveals problem accounts.

A signed patient authorization allowing the practice to disclose specified health information to a named person or organization. It must state the purpose, expiration date or event, and the patient's right to revoke.

The standard reference posture in which a person stands erect, faces forward, and has arms at the sides with palms facing forward. All directional and regional terms are based on this position.

The body's ability to maintain relatively stable internal conditions such as temperature, pH, and blood glucose despite changes in the environment. It depends on feedback mechanisms that detect and correct imbalances.

Describing a structure that is closer to the point where a limb attaches to the trunk, or closer to the origin of a structure. The opposite directional term is distal.

A word root plus a connecting vowel, usually an o, that allows the root to link with a suffix or another root when building medical terms, as in cardi/o or gastr/o.

A medical term derived from a person's name, such as Alzheimer disease or Foley catheter. Eponyms are capitalized but are generally not written in the possessive form in current usage.

A heart rate slower than the normal resting range, generally fewer than 60 beats per minute in an adult. It may be normal in well-conditioned athletes or may signal a conduction disorder.

An abnormally high level of glucose in the blood, most often associated with diabetes mellitus. Common symptoms include excessive thirst, frequent urination, fatigue, and blurred vision.

Rhythmic, wave-like contractions of smooth muscle that propel contents forward through the digestive tract and other tubular organs. It moves food, chyme, and waste along the gastrointestinal system.

The phase of the cardiac cycle in which the ventricles contract and eject blood into the aorta and pulmonary artery. It corresponds to the higher, first number recorded in a blood pressure reading.

A federal law that protects the privacy and security of health information and sets national standards for electronic transactions, patient access, and permitted disclosures. It applies to covered entities and their business associates.

Individually identifiable health information created, held, or transmitted by a covered entity, including demographics, diagnoses, and treatment details. It may be shared only as permitted by law or by patient authorization.

A patient's voluntary agreement to a procedure after receiving an explanation of its purpose, risks, benefits, and alternatives. The patient must have decision-making capacity and be given the chance to ask questions.

Failure to use the degree of care that a reasonably prudent person with similar training would use, resulting in harm. A malpractice claim generally also requires proof of duty, causation, and damages.

A legal doctrine meaning 'let the master answer,' which holds an employer liable for the acts of employees performed within the scope of their employment. It is a common basis for suing a medical practice.

The range of duties and procedures a healthcare worker is legally permitted to perform based on state law, credentialing, and employer policy. Working outside these limits can create legal and personal liability.

A person under age 18 who is legally treated as an adult for specified purposes, such as marriage, military service, or a court order. Emancipated minors may generally consent to their own medical treatment.

State statutes that limit liability for people who voluntarily provide emergency first aid in good faith without expectation of payment. Protection usually applies only when the rescuer acts within the limits of their training.