Medical Office Procedure

1 Medical Office Procedure (BAOP-100) Project # 2 October 3, 2023 Submitted by: Sandra Ekiyor Submitted to: Nisha Shekhawat

2 Table of Content 1) Introduction 2) Medical Assistant Daily Tasks and Responsibilities 3) Medical Assistant Weekly and Monthly Duties 4) List Of Physicians and Specialist 5) List Of Pharmacies 6) OHIP Billing Instructions and Samples 7) Samples Of a Referral Letter 8) Dress Code in The Office 9) Immunization Record of Employees 10) CPR And Basic Life Support Certification 11) Medical Emergency Procedure Procedure Manual About First Choice Clinic Practice First Choice Clinic was opened on October 26th 2010 when the clinic was established. It is located in City of Town and serves the rural and urban areas. The clinic is led by Dr. J.A. Smith and other three family physicians. It also hosts itinerant specialists and family practice residents. The clinic focuses on provision of emergency and urgent care to the general public during the day, in the evenings and during weekends. The closest Hospital to the Clinic is the General Community Hospital which is 12 km away.

4 Responsibilities The medical Office Assistant coordinates patient care and performs other administrative duties. The office assistant reports to health provider in charge of Human Resources. The tasks and responsibilities include To support the clinic physicians in operations and delivery of patient car. All work should meet set standards and established procedures as requested by health care providers.  Coordinate care by o checking patients o Prepping patients o escorting patients to escort rooms Monthly Tasks and Responsibilities  Order and receive office and medical supplies  Maintains electronic medical record e.g. the patient chart.  Maintain appointment schedules Monthly duties Perform all other related clinical, administrative and special tasks as required.  Be helpful, respectful and efficient  Operate fax machines  Coordinate appointment schedule and manage callers  Ensure patient confidentiality  Clean and sterilize instruments and materials  Ensure exam rooms are appropriately stocked and ready for next patient  Perform billing procedures for payers, apply and collect non- insurer fees. Office Standards  Work well as part of a team  Proficiency in computer use  Speed and accuracy  Good written and oral communication skills  Problem solving  Good judgement

5 o Preparing exams and treatment room for patient A list of physicians 1. Dr. James A. Smith MD Physician Graduated from John Hopkin University medical school in 2000 and practice residency in University of Calgary Medical School. H has obtained a master’s degree in Health Sciences with a focus on Community Health and epidemiology. Practice interests include pediatric and primary care. He is married with two sons and engages in an active lifestyle where he participates in biking, mountaineering, marathons and skiing. He keeps a standard schedule and is available on call. The following is a list of specialists where patient in First Choice can make referrals. 2. Dr. Kurban Cardiologist and heart specialist 3. Dr. Brem Mowry NEPHROLOGIST- 4. Dr. Andra Mark RESPIROLOGIST-specialist in cardiovascular and respiratory physiotherapy 5. Dr. Ellen Chetan DERMATOLOGIST 6. Dr. Gregory Dubinsky PSYCHIATRIST- Child, adolescent, youth and women psychiatry A list of pharmacies Advance Pharmacy 3456 Hillside MO

7  Get a billing number  Register by creating an online account that will allow submission of claims electronically to OHIP  Learn how OHIP claim submission process works  Get familiar with the billing codes depending on your specialty  Determine how you are going to bill. DO’S  Always Document  recognize appropriate billing  Choose experienced billing agent  Have a system for monitoring bills  OHIP DATA is classified as financial record, so keep it for up to 7 years.  Always ask for advice from experts before responding to any query. DON’T’S  Submit just before deadline  Forget to reconcile monthly  Try to justify what cannot be justified  Double down if you make a mistake by covering up  Delete or destroy medical records or change  Take the audit process for granted and delay taking action OHIP BILLING SAMPLEs Sample 1 Phillip Dikes is presented to his family doctor with enlargement on his neck and forearm. These areas were inflamed and itchy. The physician detected an urticaria but did a skin biopsy (without sutures) to confirm this. Assessment: A031 Diagnosis: 874 Procedure: Z101 Sample 2 Susan Hammock is presented to her family doctor with a sore throat. A swab (rapid strep test) was taken. He was diagnosed with strep throat and a prescription for antibiotics was given. Assessment: A012 Diagnosis: 067 Procedure: G12 SAMPLE REFFERAL LETTER MEDICAL REFERRAL LETTER

8 Date: September 20, 2023 To, {{ATTN}} {{ADDRESS}} {{POSTAL CODE}} {{COUNTRY}} Subject: Letter of Medical Obligation To Whom It May Concern / Dear Dr., I am referring {{ patient’s name }} for evaluation and consideration for a SCD pain management. I have been {{ patient’s name }} ’s primary care physician for the past {{#of yrs}} years. I have supervised several pain control and management checkups. None of these have resulted in any pain relief. As a result of this persistent pain, her/his co-morbid conditions are becoming more difficult to manage. These co-morbid conditions are as follows: Duration: Medication: 1. Acute sickle hepatic crisis 2 years Gabapentinoids, 2. Intrahepatic cholestasis 6 months ibuprofen and naproxen 3. Bone pain crisis 3 years Opioids, such as oxycodone, hydrocodone, and morphine . Pain Control will certainly make these conditions easier to manage. Since non-surgical programs have failed to provide any long-term benefits for the patient, I feel surgery is her/his only option. I hope you will find {{ patient’s name }} a suitable candidate for the surgical pain control program. It will provide a tool to assist her/him in managing pain. I anticipate that this will provide her/him with a significantly improved quality of life. If you have any questions, please feel free to contact me directly. I will be available on phone: {{T+00000000}} and email: {{email@email.com}} in case of any query. Looking forward to your reply, Yours sincerely, {{NAME}} {{Signature}} Dr. {{ Physician’ s Name}} {{Formal Name + Title}} Dress code in the office

10 In case of emergency, immediate medical attention and resuscitation should be given. Patients visiting the emergency desk should be registered after a quick preliminary assessment of the urgency and severity of their conditions by the medical officer on duty.  Call 911 from any office phone or cell phone.  Remain calm and stay with the victim/patient until help arrives.  Provide first aid if you are properly trained.  Before taking any action, consider the following: o Is the area safe for you and the victim? o Do not move victim unless safety is at risk. o Are there other victims? o If people are nearby, can they assist either with first aid or getting help? o Will bystanders need guidance so that they do not become injured or ill themselves?  Call building security (if off- campus).  Ask for assistance to keep crowds from gathering around victim.  Notify your supervisor of the occurrence.  To ensure proper documentation of the incident, provide supervisors with detailed information: o o Time of incident o o Location of incident o Description of injury/illness o Actions taken o Names of witnesses Office safety  Infection control-  Blood and fluids including saliva from patients are to be regarded as potentially harmful and infectious. Take precautions for all interactions.  Safety Practice Controls  All individuals shall war non-sterile disposable gloves when working in the lab. Gloves should not be washed or reused.  Reduce exposure to patients and staff by removing hazards.  The practices conducted will include Personal Hygiene  Professional appearance, maintenance of a clean and professional environment.  Beards, moustaches and hair must be clean and neat.  Nails should be short, clean and well-manicured.

11  Nail polish is not allowed as proper hand care promotes asepsis.  torn and cut hands promotes entry of pathogens.  Cosmetics should not be excessive.  Perfumes and fragrances should not be worn.  Smoking is discouraged.  Washing of hands is mandatory. Regards…..