Chapter One |1
Table of Contents - The Office Environment
Introduction ---------------------------------------------------------------------------------------- 1-3
Facility and Environmental Considerations ---------------------------------------------- 1-3
Exterior -------------------------------------------------------------------------------------- 1-3
Interior -------------------------------------------------------------------------------------- 1-5
Positive Impressions------------------------------------------------------------------------------ 1-5
Phone Contact -------------------------------------------------------------------------- 1-5
Attitude of Staff -------------------------------------------------------------------------- 1-6
The Waiting Room ---------------------------------------------------------------------- 1-6
Seating ------------------------------------------------------------------------------------- 1-7
Patient Visibility -------------------------------------------------------------------------- 1-7
Temperature and Ventilation ------------------------------------------------------- 1-7
Lighting ------------------------------------------------------------------------------------- 1-8
Entertainment ---------------------------------------------------------------------------- 1-8
Information -------------------------------------------------------------------------------- 1-8
The Clinical Area --------------------------------------------------------------------------------- 1-10
General Appearance ----------------------------------------------------------------- 1-10
Walls ----------------------------------------------------------------------------------------- 1-10
Floors ---------------------------------------------------------------------------------------- 1-11
Cabinets and Countertops ---------------------------------------------------------- 1-11
Examining Tables ------------------------------------------------------------------------ 1-12
Fatigue mats ------------------------------------------------------------------------------ 1-13
Stools and/or Chairs -------------------------------------------------------------------- 1-13
Chairs for Patients ----------------------------------------------------------------------- 1-13
Waste Receptacles -------------------------------------------------------------------- 1-13
Biohazard Waste Receptacle ------------------------------------------------------ 1-13
Sinks ------------------------------------------------------------------------------------------ 1-14
Writing Surface --------------------------------------------------------------------------- 1-14
Emergency Equipment---------------------------------------------------------------- 1-14
Walls for Storage ------------------------------------------------------------------------ 1-15
Safety and Comfort -------------------------------------------------------------------- 1-15
Examining and Surgical Tables ----------------------------------------------------- 1-15
Table Paper ------------------------------------------------------------------------------- 1-16
Hooks for Patient Clothing ----------------------------------------------------------- 1-16
Privacy -------------------------------------------------------------------------------------- 1-16
Care of Personal Property------------------------------------------------------------ 1-17
Examining Tables ------------------------------------------------------------------------ 1-17
Step Stools --------------------------------------------------------------------------------- 1-17
Routine Examination of Electrical Equipment --------------------------------- 1-18
Chapter One – Test Questions ------------------------------------------------------ 1-19
Derm atol ogy M edical Pol icies, Procedures and Nurse Tr aini ng M anual
©2012-2015, Ellzey Coding Solutions, Inc. All Rights Reserved.
Chapter Two |1
Table of Contents - Use of Nursing Personnel
Introduction ---------------------------------------------------------------------------------------- 2-3
The Changing Face of Dermatology --------------------------------------------- 2-3
The Insurance Industry ----------------------------------------------------------------- 2-4
Effect of Third Party Payers ----------------------------------------------------------- 2-4
One “Nurse” Each Room and One to Boot --------------------------------------------- 2-5
The “Nurse” Owns the Room -------------------------------------------------------- 2-5
Preparing the Room-------------------------------------------------------------------- 2-6
Escorting Patients ----------------------------------------------------------------------- 2-7
Situating Patient In The Examining Room --------------------------------------- 2-7
Formal Introduction or Welcome -------------------------------------------------- 2-8
Documenting the History ------------------------------------------------------------- 2-8
Gowning ----------------------------------------------------------------------------------- 2-9
Reentry Into Patient Room ----------------------------------------------------------- 2-9
Visualize The Problem ------------------------------------------------------------------ 2-9
Provide Information -------------------------------------------------------------------- 2-10
Anticipate Procedures ---------------------------------------------------------------- 2-11
Set Up For Procedure ------------------------------------------------------------------ 2-11
Prepare For Prescription Writing or Refills ---------------------------------------- 2-12
Signal Provider Patient Is Ready---------------------------------------------------- 2-12
Enter Provider----------------------------------------------------------------------------- 2-13
The Physical Examination ------------------------------------------------------------- 2-14
The “Medical Decision Making” --------------------------------------------------- 2-14
Scribing ---------------------------------------------------------------------------- 2-14
“Writing the Prescription” ---------------------------------------------------- 2-14
Assisting With Procedures------------------------------------------------------------- 2-15
Exit Provider ------------------------------------------------------------------------------- 2-15
Procedure Aftercare ------------------------------------------------------------------- 2-16
The Room Turnover --------------------------------------------------------------------- 2-17
“The One to Boot” (Triage Nurse)----------------------------------------------------------- 2-18
“I Can’t Afford That” --------------------------------------------------------------------------- 2-19
Modifications to “One Nurse Each Room” ---------------------------------------------- 2-20
One Assistant Every Other Room -------------------------------------------------- 2-20
Problems -------------------------------------------------------------------------- 2-21
Three Assistants, One Provider ------------------------------------------------------ 2-22
Derm atol ogy M edical Pol icies, Procedures and Nurse Tr aini ng M anual
©2012-2015, Ellzey Coding Solutions, Inc. All Rights Reserved.
2|Chapter Two
Forms/Abbreviations ---------------------------------------------------------------------------- 2-25
Job Description -------------------------------------------------------------------------- 2-27
Multi-drug Prescription ----------------------------------------------------------------- 2-29
Pathology Log ---------------------------------------------------------------------------- 2-31
Medications Commonly Used in Dermatology -------------------------------- 2-33
Abbreviations for Prescriptions ------------------------------------------------------ 2-35
Abbreviations for Medical Terminology ------------------------------------------ 2-37
Abbreviations for Non-Medical Terminology ----------------------------------- 2-38
Chapter Two – Test Questions ---------------------------------------------------------------- 2-39
Derm atol ogy M edical Pol icies, Procedures and Nurse Tr aini ng M anual
©2012-2015, Ellzey Coding Solutions, Inc. All Rights Reserved.
Chapter Three |1
Table of Contents - Staffing
Introduction ---------------------------------------------------------------------------------------- 3-3
Orientation of New Assistant ----------------------------------------------------------------- 3-3
Expectation ------------------------------------------------------------------------------- 3-3
Preparation ------------------------------------------------------------------------------- 3-3
Orientation Plan ------------------------------------------------------------------------- 3-3
First Week ------------------------------------------------------------------------- 3-3
Second Week ------------------------------------------------------------------- 3-4
Third Week ------------------------------------------------------------------------ 3-4
Fourth Week --------------------------------------------------------------------- 3-5
Increase Patient Load -------------------------------------------------------------------------- 3-6
Why Go Slowly --------------------------------------------------------------------------- 3-6
Increase Slowly -------------------------------------------------------------------------- 3-6
Effects of Increase ---------------------------------------------------------------------- 3-6
Forms ------------------------------------------------------------------------------------------------- 3-9
Scavenger Hunt ------------------------------------------------------------------------- 3-11
Orientation -------------------------------------------------------------------------------- 3-13
Chapter Three – Test Questions ------------------------------------------------------------- 3-19
Derm atol ogy M edical Pol icies, Procedures and Nurse Tr aini ng M anual
©2012-2015, Ellzey Coding Solutions, Inc. All Rights Reserved.
Chapter Four |1
Table of Contents - Regulatory Agencies
Introduction ---------------------------------------------------------------------------------------- 4-3
OSHA ------------------------------------------------------------------------------------------------- 4-3
Purpose of the Act ---------------------------------------------------------------------- 4-3
OSHA in the Dermatology Office -------------------------------------------------- 4-3
Bloodborne Pathogens --------------------------------------------------------------- 4-3
Hazardous Materials ------------------------------------------------------------------- 4-5
Inspections -------------------------------------------------------------------------------- 4-6
Citations ------------------------------------------------------------------------------------ 4-7
CLIA (Clinical Laboratory Improvement Amendment)------------------------------ 4-8
Mission -------------------------------------------------------------------------------------- 4-8
Classifications ---------------------------------------------------------------------------- 4-8
Manual ------------------------------------------------------------------------------------- 4-9
Impact on Clinical Staff --------------------------------------------------------------- 4-9
Inspections -------------------------------------------------------------------------------- 4-9
Proficiency Testing ---------------------------------------------------------------------- 4-10
CMS (Center for Medicare and Medicaid Services) --------------------------------- 4-11
General Orientation to Medicare ------------------------------------------------- 4-11
Provider Participation Status -------------------------------------------------------- 4-11
Participating --------------------------------------------------------------------- 4-11
Non-Participating -------------------------------------------------------------- 4-12
Rules and Regulations ----------------------------------------------------------------- 4-12
Medical Necessity ------------------------------------------------------------- 4-12
Advance Beneficiary Notice ----------------------------------------------- 4-13
Collection from the Patient ------------------------------------------------- 4-14
Medicare Compliance Program -------------------------------------------------- 4-15
HIPAA (Health Information Portability and Accountability Act) ------------------ 4-16
What is HIPAA ---------------------------------------------------------------------------- 4-16
Who is affected? ------------------------------------------------------------------------ 4-16
Are there penalties? ------------------------------------------------------------------- 4-17
How are the healthcare organizations affected ----------------------------- 4-17
Effective compliance requires organization ----------------------------------- 4-17
Rules Under HIPAA ---------------------------------------------------------------------- 4-18
Standards for Electronic Transactions ----------------------------------- 4-18
Unique Provider Identifiers --------------------------------------------------- 4-18
Derm atol ogy M edical Pol icies, Procedures and Nurse Tr aini ng M anual
©2012-2015, Ellzey Coding Solutions, Inc. All Rights Reserved.
2|Chapter Four
Privacy Rule ---------------------------------------------------------------------- 4-19
Security Rule ---------------------------------------------------------------------- 4-20
Forms ------------------------------------------------------------------------------------------------- 4-21
Advance Beneficiary Notice -------------------------------------------------------- 4-23
Chapter Four – Test Questions --------------------------------------------------------------- 4-25
Derm atol ogy M edical Pol icies, Procedures and Nurse Tr aini ng M anual
©2012-2015, Ellzey Coding Solutions, Inc. All Rights Reserved.
Chapter Five |1
Table of Contents- Quality Assurance/Risk Management
Introduction -------------------------------------------------------------------------------------------Employee Selection, Credentials, Education, Evaluation & Documentation ---The Importance of Careful Selection------------------------------------------------Average Time Required to Acquire New Staff -----------------------------------Do Not Panic --------------------------------------------------------------------------------Make Adjustments -------------------------------------------------------------------------Disadvantages ------------------------------------------------------------------------------Credential Employees Initially and Yearly -----------------------------------------Create a "Employee Tickler File"-------------------------------------------------------Check References -------------------------------------------------------------------------Education ------------------------------------------------------------------------------------Documentation ----------------------------------------------------------------------------Monitoring Medical Records --------------------------------------------------------------------Condition -------------------------------------------------------------------------------------Electronic Health Record----------------------------------------------------------------Accuracy -------------------------------------------------------------------------------------Completeness-------------------------------------------------------------------------------Monitoring ------------------------------------------------------------------------------------Medical Record Audits -------------------------------------------------------------------Patient Satisfaction Analysis ---------------------------------------------------------------------Emergency Plans (Medical, Fire, Bomb Threat, Natural Disaster, Robbery) -----Electric Equipment ---------------------------------------------------------------------------------Warranties ------------------------------------------------------------------------------------Service -----------------------------------------------------------------------------------------Documentation ----------------------------------------------------------------------------In-Service (In-house) Education ----------------------------------------------------------------Areas of education------------------------------------------------------------------------Rules regarding in-service education offerings ----------------------------------Documentation ----------------------------------------------------------------------------Critique of Meeting------------------------------------------------------------------------Evaluation of Equipment and Supplies Pre-purchase ----------------------------------Equipment ------------------------------------------------------------------------------------Supplies-----------------------------------------------------------------------------------------
5-3
5-4
5-4
5-4
5-4
5-5
5-6
5-6
5-7
5-7
5-8
5-9
5-11
5-11
5-12
5-12
5-13
5-13
5-14
5-15
5-17
5-19
5-19
5-20
5-20
5-21
5-21
5-21
5-21
5-22
5-23
5-24
5-24
Derm atol ogy M edical Pol icies, Procedures and Nurse Tr aini ng M anual
©2012-2015, Ellzey Coding Solutions, Inc. All Rights Reserved.
2|Chapter Five
Drugs, Medical Solutions, and Culture Media ---------------------------------------------- 5-25
Storage requirements ---------------------------------------------------------------------- 5-25
Cleanliness------------------------------------------------------------------------------------- 5-25
Expiration date ------------------------------------------------------------------------------- 5-28
Special Equipment (Refrigerator, Autoclave, Cryostat, Fume Hood, Special Air
Handler) ------------------------------------------------------------------------------------------------- 5-29
Refrigerator ------------------------------------------------------------------------------------ 5-29
Autoclave-------------------------------------------------------------------------------------- 5-31
Cryostat----------------------------------------------------------------------------------------- 5-33
Fume Hood ------------------------------------------------------------------------------------ 5-33
Maintenance of Surgical Instruments---------------------------------------------------------- 5-34
Types of Instruments ------------------------------------------------------------------------ 5-34
Inspection and Maintenance ----------------------------------------------------------- 5-37
Cleaning/Autoclaving/Packing/Storing --------------------------------------------- 5-39
Sterilization of Instruments----------------------------------------------------------------- 5-40
Testing the Effectiveness of Your Sterilization Process --------------------------- 5-41
Causes of Sterilization Failure ------------------------------------------------------------ 5-42
Reduce Risk to Patient and Practice ------------------------------------------------- 5-42
Forms ----------------------------------------------------------------------------------------------------- 5-45
Procedures --------------------------------------------------------------------------------------------- 5-66
Chapter Five – Test Questions -------------------------------------------------------------------- 5-91
Derm atol ogy M edical Pol icies, Procedures and Nurse Tr aini ng M anual
©2012-2015, Ellzey Coding Solutions, Inc. All Rights Reserved.
Chapter Six |1
Table of Contents- Inventory & Expense
Controlling Inventory and Expense -------------------------------------------------------- 6-1
The Six W's of Supply Smartly ----------------------------------------------------------------- 6-4
Who is responsible?--------------------------------------------------------------------- 6-4
What is stocked? ------------------------------------------------------------------------ 6-4
Why do we need it? ------------------------------------------------------------------- 6-5
Where do we get it? ------------------------------------------------------------------- 6-5
What quantity do we use?----------------------------------------------------------- 6-6
What is the cost? ------------------------------------------------------------------------ 6-6
Space for Storage of Supplies --------------------------------------------------------------- 6-7
Map the Use of the Room -------------------------------------------------------------------- 6-9
Inventory Control Systems--------------------------------------------------------------------- 6-10
What is on the Reorder Card or Spreadsheet ------------------------------------------ 6-11
Inventory and Accountability --------------------------------------------------------------- 6-12
Skin care products ---------------------------------------------------------------------- 6-12
Accountability --------------------------------------------------------------------------- 6-12
Controlled Substance Inventory ------------------------------------------------------------ 6-14
Definitions ---------------------------------------------------------------------------------- 6-14
Rules for handling Controlled Substances -------------------------------------- 6-15
Forms ------------------------------------------------------------------------------------------------ 6-17
Procedures ----------------------------------------------------------------------------------------- 6-31
Chapter Six – Test Questions------------------------------------------------------------------ 6-37
Derm atol ogy M edical Pol icies, Procedures and Nurse Tr aini ng M anual
©2012-2015, Ellzey Coding Solutions, Inc. All Rights Reserved.
Chapter Seven |1
Table of Contents- Medical Record Documentation
Introduction ---------------------------------------------------------------------------------------- 7-3
Documentation Guidelines------------------------------------------------------------------- 7-4
Separate Medical form Non-Medical Information ----------------------------------- 7-6
Use Quality History Forms ---------------------------------------------------------------------- 7-7
Components of the E/M Service ------------------------------------------------------------ 7-8
History --------------------------------------------------------------------------------------- 7-8
Chief Complaint------------------------------------------------------------------------- 7-1
History of Present Illness --------------------------------------------------------------- 7-10
Review of Systems ---------------------------------------------------------------------- 7-10
Past, Family, and Social History ----------------------------------------------------- 7-11
Examination ------------------------------------------------------------------------------- 7-13
Medical Decision Making ------------------------------------------------------------ 7-14
Number of Diagnoses or Management Options -------------------- 7-14
Amount and/or Complexity of Data to be Reviewed ------------- 7-15
Risk of Significant Complications, Morbidity and/or Mortality --- 7-15
E/M Template ------------------------------------------------------------------------------------- 7-16
E/M & Consult Matrix --------------------------------------------------------------------------- 7-17
Instructions for Using the E/M Code Selection Chart --------------------------------- 7-19
Documentation of Dermatologic Surgical Procedures ----------------------------- 7-22
Documentation ---------------------------------------------------------------------------------- 7-23 to 7-34
Chapter Seven – Test Questions ------------------------------------------------------------ 7-35
Derm atol ogy M edical Pol icies, Procedures and Nurse Tr aini ng M anual
©2012-2015, Ellzey Coding Solutions, Inc. All Rights Reserved.
Chapter Eight |1
Table of Contents - Wound Care
Introduction ---------------------------------------------------------------------------------------- 8-3
Post-Surgical Wounds --------------------------------------------------------------------------- 8-3
Wound Healing ----------------------------------------------------------------------------------- 8-3
Types of Surgical Wounds --------------------------------------------------------------------- 8-4
Destruction -------------------------------------------------------------------------------- 8-4
Sutured Surgical Wounds ------------------------------------------------------------- 8-4
Wounds Left to “Heal In” ------------------------------------------------------------- 8-4
Ulcers------------------------------------------------------------------------------------------------- 8-6
Stasis Ulcer --------------------------------------------------------------------------------- 8-6
Decubitus Ulcer -------------------------------------------------------------------------- 8-7
Track the Healing Progress ----------------------------------------------------------- 8-7
Prevent Infection --------------------------------------------------------------------------------- 8-9
Adequate preparation of the skin ------------------------------------------------ 8-9
Shaving of the hair from the skin --------------------------------------------------- 8-9
Protection of the wound from external bacteria ----------------------------- 8-9
Surgical Wound Care--------------------------------------------------------------------------- 8-10
Dressings -------------------------------------------------------------------------------------------- 8-11
Contact Layer --------------------------------------------------------------------------- 8-11
Absorbent Layer ------------------------------------------------------------------------- 8-11
Outer Layer ------------------------------------------------------------------------------- 8-11
Applying Dressings to Problem Anatomical Sites ----------------------------- 8-12
Avoid Trauma to Wound ---------------------------------------------------------------------- 8-13
Teaching the Patient --------------------------------------------------------------------------- 8-14
Prepare Patient Prior to Surgery for Post-Operative Care ----------------- 8-14
Post-Operative Instructions ---------------------------------------------------------- 8-14
Forms ------------------------------------------------------------------------------------------------- 8-17
Chapter 8 – Test Questions ------------------------------------------------------------------- 8-25
Derm atol ogy M edical Pol icies, Procedures and Nurse Tr aini ng M anual
©2012-2015, Ellzey Coding Solutions, Inc. All Rights Reserved.
C h a p t e r N i n e |1
Table of Contents- Procedures
Escorting patients between waiting room and clinical area --------------------- 9-3
Gowning the patient --------------------------------------------------------------------------- 9-5
Providing information to the patient ------------------------------------------------------ 9-7
Writing prescriptions ----------------------------------------------------------------------------- 9-9
Verification of drug to be administered -------------------------------------------------- 9-13
Drawing medication into syringe for injection ----------------------------------------- 9-15
Multi-dose vials ----------------------------------------------------------------------------------- 9-19
Administration of intramuscular injection ------------------------------------------------ 9-23
Administration of subcutaneous injection ----------------------------------------------- 9-29
Recapping needle, one-hand method -------------------------------------------------- 9-33
Loading several syringes from a multi-dose vial --------------------------------------- 9-35
Labeling of drugs or anesthetic agents -------------------------------------------------- 9-39
Skin preparation by shaving------------------------------------------------------------------ 9-43
Applying antiseptic solutions to skin ------------------------------------------------------- 9-45
Putting on sterile gloves------------------------------------------------------------------------ 9-47
Removing contaminated gloves ----------------------------------------------------------- 9-49
Autoclave cleaning----------------------------------------------------------------------------- 9-51
Handling instruments between use and cleaning ------------------------------------ 9-55
Instrument cleaning and inspection ------------------------------------------------------- 9-57
Care and storage of non-sterile instruments and new instruments-------------- 9-63
Packaging instruments for autoclaving -------------------------------------------------- 9-65
Double wrap procedure pack -------------------------------------------------------------- 9-69
Positioning knife blade on handle---------------------------------------------------------- 9-73
Removing knife blade from handle ------------------------------------------------------- 9-75
Applying sterile sheath to hyfrecator handle and cord ---------------------------- 9-77
Opening and setting up a sterile tray ----------------------------------------------------- 9-81
Adding solutions to sterile tray --------------------------------------------------------------- 9-85
Drawing injectable solutions into sterile syringe --------------------------------------- 9-87
Covering and uncovering sterile tray ----------------------------------------------------- 9-89
Acne surgery (10040) --------------------------------------------------------------------------- 9-91
Sample Operative Note -------------------------------------------------------------- 9-94
Incision and drainage (10060-10061)------------------------------------------------------ 9-95
Sample Operative Note -------------------------------------------------------------- 9-100
Derm atol ogy M edical Pol icies, Procedures and Nurse Tr aini ng M anual
©2012-2015, Ellzey Coding Solutions, Inc. All Rights Reserved.
2|Chapter Nine
Biopsy (11100-11101) ---------------------------------------------------------------------------- 9-103
Sample Operative Note--------------------------------------------------------------- 9-108
Excision and repairs ----------------------------------------------------------------------------- 9-109
Sample Operative Note--------------------------------------------------------------- 9-119
Laser -------------------------------------------------------------------------------------------------- 9-123
Laser for hair removal --------------------------------------------------------------------------- 9-127
Phototherapy -------------------------------------------------------------------------------------- 9-131
Phototherapy and photochemotherapy, body unit --------------------------------- 9-133
Photodynamic Therapy (PDT) ---------------------------------------------------------------- 9-137
Collection of Specimen for Deep Tissue Culture --------------------------------------- 9-139
Chapter Nine – Test Questions --------------------------------------------------------------- 9-141
Derm atol ogy M edical Pol icies, Procedures and Nurse Tr aini ng M anual
©2012-2015, Ellzey Coding Solutions, Inc. All Rights Reserved.
Appendices |1
Table of Contents- Appendices
Instrument Identification ----------------------------------------------------------------------- A-3
Patient Information Sheets -------------------------------------------------------------------- A-17
Acne ---------------------------------------------------------------------------------------- A-19
Actinic Keratoses (AKs) ---------------------------------------------------------------- A-21
After Your Surgery ----------------------------------------------------------------------- A-23
Alopecia (Hair Loss) -------------------------------------------------------------------- A-25
Cellulitis ------------------------------------------------------------------------------------- A-27
Color Restoration or “Repigmentation" ------------------------------------------ A-29
Dermatitis ---------------------------------------------------------------------------------- A-31
Excision and Skin Repair -------------------------------------------------------------- A-33
Liquid Nitrogen Destruction ---------------------------------------------------------- A-35
Malignant Melanoma ----------------------------------------------------------------- A-37
Psoriasis ------------------------------------------------------------------------------------- A-39
Skin Graft----------------------------------------------------------------------------------- A-41
Vitiligo --------------------------------------------------------------------------------------- A-43
5-FU and What to Expect ------------------------------------------------------------- A-45
Instructions for Use of 5-FU------------------------------------------------------------ A-47
Preference Cards -------------------------------------------------------------------------------- A-49
Acne Surgery ----------------------------------------------------------------------------- A-53
Biopsy --------------------------------------------------------------------------------------- A-55
Excision ------------------------------------------------------------------------------------- A-57
Incision and Drainage ----------------------------------------------------------------- A-59
Repairs -------------------------------------------------------------------------------------- A-61
Abbreviations And Definitions --------------------------------------------------------------- A-63
Abbreviations for Prescriptions------------------------------------------------------ A-65
Other Terms ------------------------------------------------------------------------------- A-67
Definitions and Pronunciation ------------------------------------------------------ A-69
Spelling Test ------------------------------------------------------------------------------- A-111
References and Resources ------------------------------------------------------------------- A-121
Chapter Test Answer Keys -------------------------------------------------------------------- A-127
Derm atol ogy M edical Pol icies, Procedures and Nurse Tr aini ng M anual
©2011-2015, Ellzey Coding Solutions, Inc. All Rights Reserved.