BUSINESS AND ACCOUNTING SKILLS - Health Care - ثالث ثانوي

التعليم Link to digital lesson CHAPTER www.ien.edu.sa 5 BUSINESS AND ACCOUNTING SKILLS Case Study Investigation Khalid has been a file clerk for a doctor's practice for the last four years. The practice has ten doctors. He is quite good at his job. Khalid got coronavirus and was out sick for two weeks. When he returned, files were piled everywhere! Fahad is normally a scheduler but was assigned to work together with Khalid to help him catch up with the filing and to show him how to schedule. At the end of this chapter, you will be asked to list the skills that Fahad will need to file accurately, and the talents Khalid will need to schedule patients. LEARNING OBJECTIVES After completing this chapter, you should be able to: • File records using both the alphabetical and numerical systems. • Follow correct telephone techniques when using a business telephone. • • Schedule appointments using a standard appointment ledger or a computer program. Complete registration and history records. Compose and print letters of consultation, collection, appointment, recall, and inquiry. Complete basic insurance forms accurately, neatly, and thoroughly. • Maintain a bookkeeping system. KEY TERMS answering service filing automated routing unit International Classification of Diseases patient portal triage bookkeeping voicemail buffer period electronic health record (EHR) medical history paging system 218 CHAPTER 5 ucation GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 218 14/06/2023 10:29

5:1 FILING RECORDS Filing is the systematic or orderly arrangement of papers, cards, or other materials so that they are readily available for future reference. Correct filing methods for health care records and other information are necessary for two main reasons. First, it must be possible to quickly locate the material when it is needed. Second, the material must be stored safely and protected as legal records. Various filing systems are in use. FILING SYSTEMS The most common system is to file numerically by unique identity number. Materials to be filed, such as names, are each assigned a number. The numbers are then placed in order and filed according to numerical order. The patient's name is placed on the index card or entered into the computer database along with the assigned number. The patient's file is then located in the numerical file. If patients have the same name, the numerical system can eliminate errors because each patient has their own unique number. Using only numbers on the outside of a chart also helps to protect a patient from identity theft if an unauthorized person should happen to see the chart. COLOR-CODED FILING SYSTEMS Colors provide a second means of verifying placement of folders in the file. Because a file with different color coding will stand out, a quick glance at the folders allows the person filing to immediately locate a file that is out of place. Color-coded folder systems are frequently used in larger agencies. This system uses different colored file folders (Figure 5-1). Some examples of color-coded folder systems include: • Coded by physician: A health care agency may have several doctors. Each doctor's patients have a different color file folder. One doctor's patients have yellow file folders, a second doctor's patients have green file folders, and a third doctor's patients have red file folders. Coded by type of insurance: Each type of medical of insurance has its own unique color of file folder. FIGURE 5-1 A color-coded folder system uses different colored file folders. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 219 BUSINESS AND ACCOUNTING SKILLS 219 | 14/06/2023 10:30

و230 التعليم Ministry of Education 2024-1446 CHAPTER 5 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 220 STORAGE OF FILES An efficient filing system is an important part of any health care agency. Most health care facilities use electronic databases to store information, although some facilities may still use a manual filing system. Electronic patient health records are the most efficient for storing information. In a manual system, records are stored in file folders and the folders are stored in filing cabinets or shelves. File folders must be durable and of good quality. Filing cabinets or shelves must be conveniently located, fireproof, and equipped with locks. Sufficient file space must be available so that records are not packed tightly in the filing cabinets or shelves. Because thousands of records can accumulate in a busy agency, most facilities have a policy to classify records as active, inactive, or closed. An active record is one that is currently being used because the patient is being seen by the agency. An inactive record is a record for a patient who has not been seen for a number of years. A closed record is usually a record for a patient who has died, transferred to another physician or facility, or a file that is no longer required. There may be different time requirements for retaining records. Most health care agencies keep all records in case they are needed for legal or research purposes. Inactive or closed records are frequently scanned and saved on an external hard drive or in a secure cloud or off-site server. The record can then be retrieved and displayed on the computer or printed in hard copy form if it is needed. It is important to note that the original record must be destroyed by shredding or burning to protect the confidentiality of the patient. ELECTRONIC HEALTH RECORDS Technology In an electronic filing system, agencies use computers and "paperless" files. The files are called electronic health records (EHRs). A database is created with the name, address, and case number of the patient. The database will automatically file all patient ID numbers and names in the correct order. When the patient arrives at the agency, the patient's ID number is entered into the computer and the database information with the ID number appears. Some computer programs will retrieve the patient's file by name but most will require the ID number. Once the file is retrieved, a printout can be obtained with pertinent information, or the health care provider can use a laptop computer or tablet to view and record information while providing care to the patient. When the health care provider sees the patient, current information is entered into the computerized patient file. This information can be stored on an external hard drive or in a secure cloud/off-site server so it can be retrieved when needed. Backup copies must be made frequently when an electronic system is used, because if the computer fails, or the hard drive 14/06/2023 10:30

crashes, all information would be lost. Most offices using an electronic system have automatic backups scheduled on a continuous, an hourly, or a daily basis to prevent losing information. Maintaining the confidentiality of patients' records is also essential when an electronic system is used. Passwords, firewalls, limiting access to specific people, and using secure clouds or off-site servers are methods used to prevent access to the records by unauthorized individuals. Saudi Arabia has developed the Unified Health File, which is a digital health platform providing up to date information for patients, showing history and type of disease and medicines dispensed, any medical insurance, laboratory testing results, vaccinations, and referrals. The system also contributes to unifying medical records to improve the quality of health care and patient safety. The system is available to all Saudi citizens and residents. Each person has a “national profile" in the system, which records medical information such as allergies, blood allergies, blood type, chronic diseases, height, weight, body mass index, and also any appointments or referrals, laboratory or radiology results, prescriptions, sick leave, or vaccinations. Some basic medical information can be viewed using the "Sehaty" smartphone application. checkpoint 1. What is an active record? 2. What is the Unified Health File? 5:2 USING THE TELEPHONE BASIC TELEPHONE TECHNIQUES Comm The telephone is an important tool of public relations in any health agency. Because you create an impression every time you talk on the telephone, it is important that you use correct techniques. Correct use of the telephone requires many different skills. The impression you create on the telephone will influence a patient or other caller. It is essential to be tactful, diplomatic, firm yet flexible, friendly yet professional, and courteous. You must be capable of making decisions and be willing to accept responsibility. Developing the correct tone of voice is essential. Your voice must be pleasant, low pitched, clear, and distinct. A monotone or indifferent tone should be avoided. Words must be pronounced correctly. Correct grammar should be used at all times. Courtesy and good manners must be used during the entire conversation. Remember to use the words "please” and “thank you". Always answer the telephone promptly (Figure 5-2). In addition, answer with a smile; doing so helps create a pleasant voice. Even though callers will not see the smile, they will be able to detect it in your voice. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 221 BUSINESS AND ACCOUNTING SKILLS 221 | 14/06/2023 10:30

FIGURE 5-2 Answer the telephone promptly. " Identify the office or agency-and in most cases, yourself when you answer the phone. For example, do not say "Hello,” “Yes,” or even just “Good morning,' when answering. Use greetings such as "Good morning, Dr. Al-Ali's office," "Hello, Health Care Hospital, Maha speaking," or "Respiratory Clinic, Maha speaking. How may I help you?” In this way, callers know that they have reached the correct party. In many agencies, it will be the responsibility of the receptionist to screen calls. This means that you must determine which calls should be referred to the doctor or other appropriate person, and which calls can be handled by you or another worker in the agency. Each agency usually has some policy regarding calls. For example, in some offices, calls from the doctor's immediate family (that is, wife or husband and children) and calls from other professionals are put through to the doctor. Other calls are screened to determine whether they are emergencies or whether the caller really must speak with the doctor. Experience in screening calls will help you make appropriate decisions. To screen calls, you must first obtain specific information, including: • Name of the caller: To determine the name of the caller, you should avoid statements, such as "Who is this?" or "Who are you?" It is better to say, “May I have your name, please?" or "May I ask who is calling, please?" • ID or patient number: You will also need to request the caller's ID or patient number. This will ensure that the correct records are retrieved. Birthdate: Most offices ask for the date of birth of a patient to help to verify the identity of the person calling. • Nature or purpose of the call: When patients call a health care facility, they often simply ask to talk with a particular person. By asking, “May I help you?” or "May I tell Dr. Ibrahim why you are calling?" you can usually determine the nature of the call. At times you may have to say, “Dr. Asma is with a patient at this time, may I take a message?” or “The therapist is not available at present, would you explain your problem to me so I can determine if someone else can assist you?" Emergency calls must be evaluated. In some cases, a patient is upset and there is really no emergency. Most health care agencies establish a telephone triage procedure to deal 222 CHAPTER 5 و333 التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 222 14/06/2023 10:30

with emergency calls. Triage is the process of evaluating the situation and prioritizing treatment. A list of questions is often kept by the telephone and used to assist in evaluating the situation. For example, the following questions may be used depending on the situation: • Who is the patient? • What happened? When did it happen? • Is the patient breathing? Conscious? Bleeding? • Is it possible the patient took or contacted a poison? If so, what, when, and how much? • Have you called emergency medical services? By asking pertinent questions and remaining calm, you may be able to recognize real emergencies. Most emergencies are referred to the appropriate person if they are available. If the appropriate person is not available, obtain important information so that you can help the caller obtain help from the correct source. It may be necessary to refer the patient to an emergency medical service, emergency room, or hospital. A list of emergency numbers should be readily available so the correct number can be provided to the caller. Most agencies have procedures to follow when appropriate people are not available during emergencies. Telephone triage can also be used to determine how quickly a patient should be scheduled for an appointment. Specific questions will help provide information on the seriousness of the patient's condition. Questions that might be asked include: • What symptoms are you experiencing? • How long have you had the symptoms? . Do you have a fever or elevated temperature? . • Are you having any difficulty in breathing? Are you in pain? Where? How severe? Evaluating a patient's responses will allow you to determine whether the patient should be seen immediately or can be scheduled at the next convenient appointment time. Never hesitate to ask others for advice if you are not certain about the seriousness of the patient's condition. Use discretion at all times when using the telephone. You should not say, "The doctor is having coffee down the hall,” “He isn't in yet and I don't know where he is," or similar comments. Statements such as, "He is not available at present,” or “I expect her to return at four o'clock; may I take a message?" are more appropriate. Before ending any telephone conversation, repeat important information to the caller. For example, say, "Your appointment is scheduled for 10:00am وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 223 BUSINESS AND ACCOUNTING SKILLS 223 | 14/06/2023 10:30

For Date. M. Of Phone Fax. Time. WHILE YOU WERE OUT Mobile. Ama Code Number TELEPHONED CAME TO SEE YOU WANTS TO SEE YOU RETURNED YOUR CALL Message PLEASE CALL WILL CALL AGAIN URGENT SPECIAL ATTENTION on 10th Rajab," or "The doctor will return your call after 4pm today." At the end of a conversation, always close with, “Thank you for calling. Goodbye," and end the call gently. If possible, allow the caller to hang up first. If you hang up first, you might miss something the patient wanted to say. In most agencies, written notes are made of any calls that require action. These notes can be handwritten or entered into a computer database or into the patient's EHR. In other agencies, telephone logs are kept, and every call is recorded. The log must be accurate. Telephone messages should always contain the following information (Figure 5-3A): • • Name of the caller: Note the caller's full name. Make sure that it is spelled correctly. Telephone number of the caller: Include the full number. If there is a specific time when the caller can be reached, add this information. Message: Briefly summarize the reason for the call but include all important information. • Date and time of the call. • Action required: If any action was taken, record what was done. If action must be taken, record the required action, such as "will call back," "please call back," or "please call after 3pm." . • Name of the person taking the message: If the message recipient has any questions, they will know who to ask. A.M. P.M. Extension VOICEMAIL 3DEF 5 6 # D-:NOHd Signed FIGURE 5-3A A sample telephone message form provides the receiver with all the information required to respond to the message. FIGURE 5-3B Message pads that provide a duplicate of each telephone memorandum can be used to create a telephone log. 224 و331 التعليم Ministry of Education 2024-1446 CHAPTER 5 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 224 14/06/2023 10:30

If an agency uses handwritten forms, it is essential to keep a pencil or pen and paper by the telephone. Some agencies use telephone message pads. If a copy of the message is needed for the patient's record or the agency's telephone log, message pads that provide a duplicate copy of each memorandum recorded can be purchased (Figure 5-3B). When recording any messages, always print them clearly. Include all important facts and spell words correctly. Using a headset with the telephone frees the operator's hands and makes it easier to record telephone memorandums or key messages into a computer. Electronic health record systems frequently include the use of patient portals, or secure online websites that are established by a physician, health care facility, or other health care provider. Patients are given an access code to register for the portal so they can log in anytime to gain electronic access to their EHR. This allows patients to request prescription refills, ask questions, request or verify an appointment, view laboratory reports, and perform other similar tasks. When a patient request or question is sent electronically, the system sends an alert that must be answered. These requests or questions must be routed to the appropriate individual in the same manner as telephone requests or questions. Problem calls can occur in any agency. Some individuals may refuse to give their names or state the purposes of their calls. At times, they may try to intimidate or threaten the person answering the phone. Try to remain calm and to control your temper. Do not hesitate to say, "Dr. Asma cannot be disturbed unless I can tell her who is calling.” Be polite but firm in dealing with this type of caller. If a caller gives their name but refuses to state the general purpose of the call, this situation also requires tact. When in doubt, you can put the call on hold and check with the person whom the caller wants. That person can then determine whether to take the call. If a call must be put on hold or you know there will be a slight delay before the appropriate person answers the call, ask the caller, "May I put you on hold for a moment?” Make sure the patient consents to being put on hold before placing a hold on the call. Never leave a caller on hold for longer than 1 minute. If there is a delay, offer to take the caller's number and have the individual return the call. Be considerate of all callers. Correct telephone techniques require practice and experience. Think about the kind of impression you want to create; practice correct responses. At all times, think before you speak. Avoid comments that might offend a caller. Treat callers as you would want to be treated if you were the caller. AUTOMATIC ROUTING TELEPHONE SYSTEMS Many health care facilities have telephone systems with an automated routing unit. This type of system allows many telephone calls to be answered at the same time. The system answers the telephone and a recorded voice provides directions to the caller. Most systems provide وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 225 BUSINESS AND ACCOUNTING SKILLS 225 | 14/06/2023 10:30

و236 التعليم Ministry of Education 2024-1446 CHAPTER 5 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 226 a menu with a series of numbers. The caller presses the correct number to connect with a specific department or individual. The routing system can be programmed so a caller with an emergency can be transferred immediately to an individual who can handle the emergency. Voicemail is a common feature of most automated routing systems. If the individual is not available, the caller is instructed to leave a message or directed to contact another person. It is essential that individuals with voicemail check messages frequently. Most telephones will provide a signal, such as a beep, to alert the individual that messages are on the voicemail system. An individual who does not respond to voicemail messages creates poor public relations. ANSWERING SERVICES AND MACHINES An answering service is used by many health care agencies to respond to telephone calls when staff are unavailable. This allows the patient to talk with an operator at the answering service who can transfer the call to the appropriate individual, contact the individual and ask them to call the patient, or record a message. The health care agency provides the operator with procedures to follow in case of an emergency, telephone numbers of individuals who may have to be contacted, and guidelines for a variety of calls. The health care agency usually pays a monthly fee for this service. An answering machine is used in some health care agencies, but it is not as efficient as an answering service. The recording on the answering machine usually identifies the agency and asks the caller to leave a message. Some health care agencies also include the hours they are open on the recording. If an answering machine is used, the message on the machine should tell patients what to do in case of an emergency. Most agencies provide an alternative number a patient can call for an emergency. The answering machine must be checked frequently for messages. A designated individual should check for messages immediately after the agency opens and at frequent intervals if the machine is used while the agency is open. PAGING SYSTEMS A paging system allows an individual to be contacted by using a pager or beeper. The pager can provide a voice message, a signal, such as a beep that alerts the individual to call a designated number to receive the message, or a digital message on a display screen with the telephone number of the caller or a message. The type of message received depends on the paging system used. Pagers are used to contact an individual. Most do not allow for two-way communication, but they do allow access to the individual 24 hours a day. The individual receiving the pager message must use a telephone to contact the caller. Newer two-way pagers can be used to both 14/06/2023 10:30

receive and send messages, eliminating the need for the receiver to use a telephone to respond to the page. The health care agency usually pays a monthly fee for each pager in use. CELLULAR TELEPHONES A mobile (cellular) telephone or smartphone allows two-way communication between people in almost any location. They provide much more flexibility for an individual to receive calls. It is more efficient than a pager because the individual does not have to use another telephone to respond. ELECTRONIC MAIL Electronic mail, or e-mail, allows an individual to use an Internet connection to send, receive, and forward messages in digital form. The e-mail message can be sent to another individual in place of a telephone call or letter. Insurance companies, billing services, and health care agencies use e-mail messages to communicate with each other. In large health care agencies where computers are networked (electronically connected to each other), an e-mail message can be forwarded to many staff members at the same time and take the place of a written interoffice message. If an e-mail message is transmitted through the Internet on a modem that is not secure, it can be intercepted and read by others. For this reason, confidential patient information should not be sent unless a strong encryption program, firewall, or password protection is used. checkpoint 1. What information do you need to be able to screen a telephone call? 2. When taking a telephone message, what are six components that messages should always contain? 5:3 SCHEDULING APPOINTMENTS One of the most frequent complaints that patients voice regarding doctor's offices, clinics, and other health agencies is having to spend a lot of time sitting in waiting rooms before getting to see doctors or other appropriate health personnel. To prevent this as much as possible, offices use a carefully planned appointment schedule. Correct scheduling of appointments is essential for good public relations. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 227 BUSINESS AND ACCOUNTING SKILLS 227 | 14/06/2023 10:30

Patient Appointment Detaily Patient Appointment FIGURE 5-4A In most health care agencies, appointment scheduling is done by computer. FIGURE 5-4B A sample computer screen showing an appointment that has been scheduled. In most health care agencies, appointment scheduling is done by computer (Figures 5-4A and 5-4B). The computer automatically locates the next available date and time, provides a record of appointments already scheduled, can be programmed to schedule a set block of time for a particular procedure, and prints out copies of the daily schedule. Although computerized scheduling can be efficient and convenient, an alternate system must exist for downtime, or times when the computer is not functioning. If the computer program is not working, or is not available in an office, appointment books or logs may be used. Appointment books or logs vary from office to office. However, most contain one or one-half page for each day. Time is usually blocked off in units of 10-15 minutes so that all time can be used wisely. Become familiar with the type of appointment book you will use and know what block of time each line represents. An organized approach is needed to avoid scheduling patients at times when the appropriate person is not available. When scheduling appointments, take into account the daily rest period and meetings, and avoid scheduling any appointments during these periods. A large X is usually drawn through each of these time periods so that no scheduling errors can occur. With computer scheduling, some programs highlight the block-out times in a different color or use lines to mark off the times. If an appointment book or log is used to schedule appointments, most agencies use a pencil to record the appointments. In this way, if an appointment is canceled, names can be erased, and the time can be assigned for another patient. Follow your agency's procedure. و238 التعليم Ministry of Education 2024-1446 CHAPTER 5 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 228 14/06/2023 10:30

Before scheduling any appointment, determine how long various procedures in your agency take. If an examination takes 1 hour and you schedule a 15-minute appointment, you will be 45 minutes behind for later appointments. Many agencies keep lists of standard procedures and the average time required for each near the appointment book. An example is shown in Table 5-1. Procedure Time (minutes) Amalgam restoration 30 Composite restoration 30 Crown preparation Crown placement Denture placement 45-60 15-20 15 Denture preparation 30-45 Examination (initial) 30 Examination (general) 15 Extraction 30-45 Prophylactic (general) 30-45 Root canal 45-60 Whitening 45-60 TABLE 5-1 Procedure scheduling times. Appointments should be scheduled as close together as possible, but not so close that patients will feel rushed in the office or be required to wait for long periods. Long periods of unscheduled time are wasteful and cost money. Some agencies schedule a 15-30 minute buffer period in the middle of each morning and afternoon. This allows time to catch up if some appointments run over. If the appointments run as scheduled, this time can be used for other business, such as returning telephone calls or seeing patients with emergencies. When a patient calls for an appointment, find out the reason for the appointment. Then try to accommodate the patient by scheduling an appointment convenient for them. Questions, such as, “Do you prefer morning or afternoon?" "Which day is most convenient?" and "Would two o'clock or four o'clock be more convenient?" give the patient a choice and help you select the correct time and day. Sometimes, choices are limited because the appointment schedule is full. However, by giving patients as much choice as possible, you let them know that you are trying to accommodate them. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 229 BUSINESS AND ACCOUNTING SKILLS 229 | 14/06/2023 10:30

و 230 التعليم Ministry of Education 2024-1446 CHAPTER 5 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 230 MONDAY DAY DATE FEB. 8, 20-- 9:00 * (CONFERENCE-DEPARTMENT HEADS) 9:15 9:30 YASSER-CHEST X-RAY-555-4328 SARA - DIET CHECK-555-3811 9:45 10:00 NOURA-555-3428 TOENAIL SURGERY 10:15 10:30 (BUFFER) SULTAN - PHYS. EX. – 555-5318 - 10:45 11:00 11:15 11:30 CHILDREN: FAISAL, REEM, SAUD 11:45 12:00 (LUNCH) 12:15 IMMUNIZATIONS * FIGURE 5-5 A sample appointment schedule. Comm Make sure you have the required information before closing your conversation with the patient. Obtain the full name of the patient. Do not hesitate to ask the patient to spell the name if you are not sure of the correct spelling. Determine the reason for the appointment. It is also wise to get the patient's telephone number in case an emergency requires cancellation of the appointment. Writing the telephone number in the appointment ledger eliminates having to find the number in the patient's record and saves time. Repeat the date, day, and exact time of the appointment to the patient. By giving both date and day, you provide a double check and prevent errors. Make sure the patient understands all information. Before hanging up the phone, you can again repeat the information by saying, “We will expect you Friday, March 1st, at two o'clock. Thank you for calling, Mrs. Shahad. Goodbye." 14/06/2023 10:30

If a patient schedules an appointment at the health care facility, an appointment card or printed sheet should be given to the patient. The card/sheet should state the date, day, and time of the appointment. Many health care facilities also use e-mail, text messages, or telephone calls to send appointment reminders to their patients, so make sure you follow the policy in place at your facility. After scheduling an appointment, make sure that you mark the full amount of time in the schedule. In many agencies, arrows are used that extend down from the patient's name to fill in the entire time block the patient will require (Figure 5-5). This also prevents scheduling errors. A computer system will usually automatically block off the time required based on the procedure entered. If a patient calls to cancel an appointment, be polite. Ask the patient if they would like to reschedule the appointment. Delete the appointment on the computerized schedule or remove it from the printed schedule by drawing a single line through the entry. Then record all new information in the correct time block. It is not necessary to pry and ask patients why they must cancel. Many patients will offer explanations; however, if they do not, do not question them. Chronic scheduling problems occur in every agency. Some patients schedule appointments and then do not show up for them. If a patient becomes a chronic offender, there are several methods of dealing with the problem. One method is to schedule the patient at the end of the day. This way, if the patient does not keep the appointment, other patients and the schedule will be minimally affected. In most agencies, canceled appointments or "no-shows" are noted on patients' charts. If the individual who canceled or did not appear for an appointment needs continuing care, efforts must be made to contact the person. Most agencies have a policy that requires calling the patient and recording the date and time of each call on the patient's chart. If there is no response from the patient after several telephone calls, a letter or e-mail is sent to the patient explaining the need for care. Documenting all efforts in the patient's chart provides legal protection if the patient files a lawsuit. The final decision on how to deal with these situations rests with the individual in charge. Emergencies occur in every agency. In the case of an emergency, appointments may run later than scheduled. Sometimes, it is necessary to cancel all appointments scheduled. If possible, patients should be notified by telephone before they come to the office or agency. When you call to cancel an appointment, make every effort to reschedule the patient at a time convenient to them. If a patient arrives at the office and appointments are behind schedule, offer the patient a choice between waiting or scheduling another appointment. If told that an emergency has occurred (the full nature of the emergency need not be explained) and they will have to wait, many patients will be willing to do so. However, patients should never be left waiting without an explanation. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 231 BUSINESS AND ACCOUNTING SKILLS 231 | 14/06/2023 10:30

و333 التعليم Ministry of Education 2024-1446 CHAPTER 5 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 232 Correctly scheduling appointments takes practice. If your present system is resulting in long waits for patients, review your system. Determine whether longer time periods are necessary for each patient. Add additional buffer times for overlap or emergency patients, if indicated. Constantly be willing to try to correct problems and create a good impression of the agency. checkpoint 1. Why do some offices schedule a buffer period in the middle of the morning? 2. How can a patient who repeatedly misses appointments be approached? 5:4 COMPLETING MEDICAL RECORDS AND FORMS Medical records vary. Two common forms are patient information forms and medical history forms. These forms can be printed and completed manually, or the information can be entered into a computer database or EHR. All records are considered to be confidential. No information can be released from the records without the written consent of the patient. These forms belong to the physician or agency. They should be locked up or electronically secured when not in use. Patient information forms are also called patient registration forms (Figure 5-6). This form is usually completed on a patient's first visit to an office or health agency. On subsequent visits, patients are asked to verify the information to be sure it is correct. The patient information form contains patient demographics. The form may be a sheet of paper or the inside of the patient's folder. In most offices, the information is entered into a computer database on the patient's EHR. Sample computer entry screens for patient information and insurance information are shown in Figures 5-7A and 5-7B. No matter what type of form is used, most contain the following information: • Patient's name in full. • Patient's address. • Patient's telephone number. • Patient's e-mail address. • Patient's marital status, sex, and birthdate. • Patient's place of employment. • Name of the person responsible for the account (if paying). • Insurance company information, including name of company, address, policy and group numbers, and other pertinent information. 14/06/2023 10:30

PATIENT INFORMATION PATIENT'S NAME STREET ADDRESS CELL PHONE NUMBER PATIENT'S EMPLOYER EMPLOYER'S STREET ADDRESS IN CASE OF EMERGENCY CONTACT: SPOUSE'S NAME CELL PHONE NUMBER SPOUSE'S EMPLOYER EMPLOYER'S STREET ADDRESS DATE: MARITAL STATUS DATE OF BIRTH NATIONAL ID NO. S M W DIV SEP PERMANENT TEMPORARY CITY, AREA, BUILDING NUMBER POSTCODE HOME PHONE NO. WHO REFERRED YOU TO THIS PRACTICE? IF THE PATIENT IS A MINOR OR STUDENT MOTHER'S NAME MOTHER'S EMPLOYER EMPLOYER'S STREET ADDRESS FATHER'S NAME FATHER'S EMPLOYER EMPLOYER'S STREET ADDRESS INSURANCE INFORMATION PERSON RESPONSIBLE FOR PAYMENT, IF NOT ABOVE ☐ COMPANY NAME & ADDRESS ☐ COMPANY NAME & ADDRESS ☐ COMPANY NAME & ADDRESS E-MAIL ADDRESS OCCUPATION (INDICATE IF STUDENT) HOW LONG EMPLOYED? BUSINESS PHONE NO. CITY, AREA, BUILDING NUMBER POSTCODE E-MAIL ADDRESS DRIVERS LIC. NO. OCCUPATION (INDICATE IF STUDENT) HOW LONG EMPLOYED? BUSINESS PHONE NO. CITY, AREA, BUILDING NUMBER POSTCODE ADDRESS, CITY, AREA, BUILDING NUMBER, POSTCODE OCCUPATION CITY, AREA, BUILDING NUMBER HOME PHONE NO. HOW LONG EMPLOYED? BUSINESS PHONE NO. ADDRESS, CITY, AREA, BUILDING NUMBER, POSTCODE OCCUPATION CITY, AREA, BUILDING NUMBER POSTCODE HOME PHONE NO. HOW LONG EMPLOYED? BUSINESS PHONE NO. ADDRESS, CITY, AREA, BUILDING NUMBER, POSTCODE NAME OF POLICYHOLDER NAME OF POLICYHOLDER NAME OF POLICYHOLDER POSTCODE HOME PHONE NO. CERTIFICATE NO. GROUP NO. POLICY NO. POLICY NO. AUTHORIZATION: I hereby authorize the physician indicated above to furnish information to insurance carriers concerning this illness/accident, and I hereby irrevocably assign to the doctor all payments for medical services rendered. I understand that I am financially responsible for all charges whether or not covered by insurance. FIGURE 5-6 A sample patient information form. RE 5- وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 233 Responsible Party Signature BUSINESS AND ACCOUNTING SKILLS 233 | 14/06/2023 10:30

Physician: Secondary Insurance | Other Information and Coverage Patient Information Spouse/Parent / Other Primary Insurance Insurance Plan: Policy Holder Information Last Name: First Name: Patient's relationship to the policyholder: Self Spouse Child Other Patient Registration Patient Account: Secondary Insurance Spouse/Parent / Other Last Name: First Name: Physician: Other Information and Coverage | Primary Insurance Patient Information National ID No.: Patient Registration Patient Account: Gender: Marital Status: Date of Birth: Address: Employment Status: City: Employer/School: Area: Employer Address: Date of Birth: National ID No.: Building No.: Postcode: City: Policy Number: Home Phone: Area: Postcode: Work Phone: Ext: Referral Source: Group Number: Employer Name: Save New Entry Delete Close Responsible Party: Self Guarantor Save Close Office Co-pay: Accept Assignment: Yes Signature on File: Yes No No In-Network/PAR: Yes No 15: PCP: FIGURE 5-7A A sample computer database screen for patient information. FIGURE 5-7B A sample computer database screen for insurance information. و230 التعليم Ministry of Education 2024-1446 CHAPTER 5 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 234 . Name of referring physician or other person. In most agencies, this information is keyed into a computer database and a printed copy is placed in the patient's record or the information is included in the patient's EHR. Care must be taken to ensure that all information is accurate. Double-check numbers and spelling. A medical history form (Figure 5-8) is another important form used in almost all health care agencies. Information on this form helps the practitioner provide better care and, at times, even make a diagnosis. A medical history can be recorded on a form or entered into a computer database on the patient's EHR. These forms also vary but most forms contain the following basic parts: • General information: This includes name, address, age, and other similar information. Family history: Family history includes information on members of the patient's immediate family, including parents, grandparents, sisters, and brothers. Questions are asked regarding heart disease, cancer, mental disorders, diabetes, epilepsy, kidney disease, and allergies. If a family member has died, the cause of death and age at time of death are recorded. Only information regarding blood relatives is obtained. Information regarding relatives by marriage, such as a mother-in-law, is not obtained because the patient cannot inherit diseases from these individuals. • Patient's medical history: Medical history includes past illnesses, treatments, operations, accidents, physical defects, allergies, childhood diseases, and other similar items. For each past illness, the year of the illness or the patient's age at the time of the illness is recorded. For each past operation, the date of the operation or the age of the patient at the time of the operation and the type of operation are recorded. 14/06/2023 10:30

Date Patient's name MEDICAL HISTORY FORM Age Address Phone ( ) Insurance company Place of employment Phone () Parent/Guardian if minor Address Phone ( ) Family History: Date of birth City Cell phone number Policy number Address Job responsibilities City Cell phone number Sex Postcode E-mail address Postcode E-mail address List family members: (mother, father, brothers, sisters, grandparents, etc.)-ages and health status (if deceased write their age at the time of their death and the cause). List allergies and/or any conditions or diseases they may have or have had, such as asthma, arthritis, tuberculosis, diabetes, cancer, heart disease, hypertension, kidney disease, mental illness, depression, or any other health problems that you know of in your family. Patient's Past History: Mark the boxes to the right either "yes" or "no" for the following questions:* Do you ever have or have you ever had any of the following: SKIN (Yes) (No) Scarlet fever or rheumatic fever Chest pain ( ) ( ) ( ) ( ) Diabetes Rashes, hives, itching or other skin irritations Heart palpitations or rapid heart- beat or pulse Thyroid or goiter Swollen glands ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) EYES, EARS, NOSE, THROAT High blood pressure Swelling of hands and/or feet ( ) ( ) ( ) ( ) or Bright's disease Headaches, dizziness, fainting ( ) ( ) GASTROINTESTINAL Blurred or impaired vision ( ) ( ) Heartburn or indigestion ( ) ( ) Hearing loss or ringing in the ears ( ) ( ) Discharge from eyes or ears Sinus trouble/colds/allergies Nausea and/or vomiting ( ) ( ) ( ) ( ) Loss of appetite ( ) ( ) ( ) ( ) Belching or gas ( ) ( ) Asthma or hay fever ( ) ( ) Peptic ulcer, gallbladder or GENITOURINARY Kidney disease or stones, Painful, frequent or urgent urination ( ) ( ) Blood or pus in urine Sexually transmitted disease (venereal disease) NEUROMUSCULAR Problems with becoming tired ( ) ( ) ( ) ( ) ( ) ( ) Sore throats/hoarseness CARDIOPULMONARY Shortness of breath Persistent cough or coughing up ( ) ( ) liver disease ( ) ( ) and/or upset easily ( ) ( ) Yellow jaundice or hepatitis ( ) ( ) Nervous breakdown/depression ( ) ( ) ( ) ( ) Diarrhea or constipation Dysentery ( ) ( ) ( ) ( ) Poliomyelitis (infantile paralysis) ( ) ( ) Convulsions ( ) ( ) blood or other secretions Chills and/or fever ( ) ( ) ( ) ( ) Rectal bleeding, hemorrhoids (piles)( ) ( ) Tarry or clay-colored stools Night sweats Tuberculosis or exposed to TB ( ) ( ) GLANDS ( ) Weight gain or loss ( ) ( ) ( ) ( ) Joint and/or muscular pain Back pain or injury/osteomyelitis/ rheumatism ( ) ( ( ) ( ) Are you currently taking any medications? Yes ( ) No ( ) Last menstrual period If yes, please list them Birth control Have you ever had or been treated for cancer or any tumors? List dates of all operations/surgeries, injuries, and illnesses that required hospitalization: Are you anemic or have you ever had to take iron medication? Do you use tobacco? What type? WOMEN ONLY Painful menstrual periods Pregnancy/abortion/miscarriage Vaginal infection or discharge/ abnormal bleeding 0 00 000 C 0 00 000 0 ( ) Did you ever receive benefits from a medical insurance claim due to illness or injury? Yes ( ) No ( ) Were you ever rejected from the military or for employment? ( ) ( ) Were you absent from school/work in the past 10 years because of illness or injury? ( ) ( ) Did you ever seek psychological or ( ) ( ) psychiatric treatment? ( ) ( ) FIGURE 5-8 A sample medical history form. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 235 *Please use the back of this form to explain any "yes" answers. Thank you. BUSINESS AND ACCOUNTING SKILLS 235 | 14/06/2023 10:30

FIGURE 5-9 Make sure the patient has complete privacy while completing the medical history form. • Personal/Social history: This may include questions about the patient's diet, sleep, or exercise routines and personal habits, such as smoking. In the case of a female patient, information regarding pregnancies, number of children, and menstrual pattern is also recorded. A list of current medications being taken by the patient is usually requested. · . Present illness or ailment: This is an exact description of the signs and symptoms the patient is currently experiencing. Information about when the illness first occurred, any previous treatment, and other pertinent information offered by the patient should be noted. This section is sometimes designated as chief complaint. Physical examination: The physician performs an examination of all body systems and records both positive and negative findings. This section may also include results from laboratory tests, although there is sometimes a separate section for laboratory tests. Diagnosis, prognosis, treatment: These sections can be separate or combined on the form. They are completed by the physician after all the previous information is reviewed. The diagnosis is the physician's judgment regarding what disease or condition the patient has. Sometimes a tentative diagnosis is listed, or the physician may write "R/O" followed by the name of one or more diseases to indicate that tests should be done to rule out the diseases listed. The prognosis is the physician's opinion regarding the course and expected outcome of the disease or condition, such as “full recovery in 1-2 weeks". Any specific treatment given is also listed. In most agencies, the health care assistant will complete only the patient information and family history, patient's medical history, and personal history sections. Patients may also be asked to complete a form providing this information, which can then be checked by the assistant or physician. The physician or another authorized person will do all other parts of the medical history. و236 التعليم Ministry of Education 2024-1446 CHAPTER 5 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 236 14/06/2023 10:30

Comm Make sure the patient has complete privacy while completing the medical history form (Figure 5-9). A separate room should be used, and the door to the room should be closed. Specific questions must be asked. It is essential that questions be asked in a professional rather than prying manner. It is also important to make sure the patient understands the meaning of all questions. For example, you may have to explain to the patient that diabetes is a disease caused by eating sugars. Information obtained must be accurate and complete. Facts should be rechecked as necessary. The patient should be given time to think about each question. It is important that the patient feels relaxed and at ease during the questioning. Note any additional information that the patient provides if it seems important to the overall history. If no specific areas are provided on the forms for this type of information, be sure the physician or other appropriate person is made aware of the information. Legal requirements must be observed while working with medical records. It is essential to remember that all information on the record is confidential and cannot be given to any other individual, agency, or insurance company without the written permission of the patient. Records must be stored in a secure, locked area with limited access. Computerized records must use encryption technology, firewalls, or password protection. The final version of the medical history record is usually keyed into a computer program and printed for the patient's permanent record, or it is included in the patient's EHR. Make sure that any handwritten copy is legible and clear. Double-check all information to make sure that it has been recorded correctly. checkpoint 1. What information is contained on a patient information form? 2. Where is a patient's medical history stored? 5:5 COMPOSING BUSINESS LETTERS TYPES OF LETTERS Comm There are many different types of business letters. Some types of business letters that you may be required to prepare include: Appointment letter: Informs a patient of a scheduled appointment. All information, including the day, date, and time must be included in the letter. In many agencies, appointment reminders are sent by e-mail or SMS message. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 237 BUSINESS AND ACCOUNTING SKILLS 237 | 14/06/2023 10:30

و238 التعليم Ministry of Education 2024-1446 CHAPTER 5 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 238 • Recall letter: Reminds a patient that it is time to return for a periodic examination. A reminder letter for a postoperative check-up is one example. In some agencies, recall cards, e-mails, or SMS messages are sent to patients. . • Consultation letter: Sent to another professional to request an examination of a particular patient. It is sometimes used as a referral to another physician, therapist, or treatment/diagnostic agency. • Inquiry letter: Seeks some information. A letter asking a patient for information about medical insurance is one example. PARTS OF A LETTER Every letter must include certain parts. The parts and their components are as follows: • Letterhead (or heading): In most cases, a computer template is used to create letters and the letterhead or heading is saved in the template. The agency's name, address, and telephone number are populated in the template and will print off with the letter. Some health care agencies also include their website address and e-mail address. In some agencies, printed stationery is used, and the agency's name, address, and phone number are printed on the paper as the letterhead. • Date line: The date the letter is being written is keyed under the letterhead. • Inside address: This is the name and address of the person or firm to whom the letter is being sent. . • . Salutation: This is the name of the person to whom the letter is directed. The salutation should include the title, followed by the last name of the person. If the letter is addressed to a title (for example, human resources manager), the salutation should read Dear Human Resources Manager or To Whom It May Concern. Subject line: Some letters may include a subject line to reference the reason for writing. This is not present in all letters. Body: This is the message of the letter. Most letters include three paragraphs. The first paragraph states why the letter is being written. The second paragraph lists the main facts. The third paragraph is the sign-off or final reminder. Complimentary close: This is a courtesy, most commonly Sincerely, Sincerely yours, Respectfully yours, or Yours truly. Only the first word of the complimentary close is capitalized. Signature: The signature is the name and title of the person writing the letter. Leave space after the complimentary close for a handwritten signature, and then key the name and title of the person who is sending the letter. 14/06/2023 10:30

• Reference initials: Reference initials are the initials of the person dictating the letter and the initials of the person preparing the letter, or the initials of just the preparer. Enclosure notation: If enclosures are included with the letter, this is noted at the end, with a brief description of the material enclosed. PROPER FORM FOR LETTERS When keying a letter into a computer, it is important to follow specific rules and use correct spacing. Some of the main points to observe are as follows: • All letters must be neat and professional. Spelling and punctuation must be correct. Use the spelling and grammar checks on the computer to correct errors. Use a dictionary to check medical or dental terms that might not be included on the word processing program's spell-checker. Date Line AMC 2332 Olaya St., Al Olaya Area Riyadh 11433 January 12, 20 (approximately 15th line) Alolaya Medical Center Riyadh City Inside Address Dr. Salutation Subject Line Body Complimentary Closing Saleh Saad (approximately 20th line) Jeddah, Saudi Arabia PO Box 40111 (double-space) Dear Dr. Saleh Saad: (double-space) Saudi Society for Family & Community Medicine Meeting (double-space) Thank you for inviting me to speak at the Saudi Society for Family & Community Medicine Meeting June 15, 20 As requested, my topic will describe the use of the MRI in assisting physicians to make a more accurate diagnosis without resorting to invasive procedures. The exact title of my speech will be sent by next Friday. (double-space) Please have your office manager send information regarding the number of participants expected, time of meeting, location, and any other details that will assist me in preparing my speech. I will write or call if I have any additional questions. (double-space) Yours truly, Keyed Signature (4-5 line spaces) Dr. Yasser Abdullah (double-space) Reference Initials YA (double-space) Enclosure Notation Enclosure: Handout on MRI FIGURE 5-10 The form for a block style letter. All sections are aligned at the left margin. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 239 BUSINESS AND ACCOUNTING SKILLS 239 | 14/06/2023 10:30

و290 التعليم Ministry of Education 2024-1446 CHAPTER 5 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 240 AMC 2332 OLAYA ST. AL OLAYA AREA RIYADH 11433 ALOLAYA MEDICAL CENTER RIYADH CITY January 12, 20 (approximately 15th line) Dr. Saleh Saad (approximately 20th line) Jeddah, Saudi Arabia PO Box 40111 Dear Dr. Saleh Saad: Saudi Society for Family & Community Medicine Meeting the Saudi Society for Family & . Thank you for inviting me to speak at Community Medicine Meeting June 15, 20 As requested, my topic will describe the use of the MRI in assisting physicians to make a more accurate diagnosis with-out resorting to invasive procedures. The exact title of my speech will be sent by next Friday. Please have your office manager send information regarding the number of participants expected, time of meeting, location, and any other details that will assist me in preparing my speech. I will write or call if I have any additional questions. YA Enclosure: Handout on MRI Yours truly, с Dr. Yasser Abdullah FIGURE 5-11 The form for a modified block style letter. . • The style for letters varies. Two common styles are block style and modified block style. In block style (Figure 5-10), all parts of the letter are aligned starting at the left margin of the paper. In modified block style (Figure 5-11), certain parts of the letter are aligned at the center line of the paper and the remaining parts are aligned at the left margin of the paper. If a computer template with a populated letterhead is used, space down three to four lines below the letterhead. Begin keying at the center line for modified block style or at the left margin for block style. Key in the month, day, and year. Do not abbreviate the month. If a letterhead is printed on the paper, space down approximately 15 lines from the top of the document. Begin keying at the center line for modified block style or at the left margin for block style. Key in the month, day, and year. Do not abbreviate the month. 14/06/2023 10:30

وزارة التعليم Ministry of Education 2024-1446 Space down five lines and begin the inside address on the fifth line below the last line of the heading. Start at the left margin line regardless of style. The inside address should be at least three lines long. The first line is the name and title (for example, Mr. or Ms.) of the person to whom the letter is being sent. Never use a double title, such as Dr. D. A. Safa, M.D.; rather, use D. A. Safa, M.D. The second line is the building number and street. The third line is the district, and the next the postal code, followed by the city. Space down two lines and begin the salutation on the second line below the inside address. Start on the left margin regardless of style. • If a subject line is included, space down two lines below the salutation. Begin keying at the left margin to insert the subject of the letter. . . • Space down two lines and begin keying the body on the second line after the salutation or subject line. Start each line of the body on the left margin. In most cases, the first line of any paragraph in either modified block style or block style is not indented. Some agencies, however, may indent the first line of each paragraph five spaces in a modified block style letter. Space down two lines after the last sentence in the body and begin keying the close. Start at the center line for modified block style or at the left margin for block style. Capitalize only the first word of the complimentary close and place a comma at the end of the close, for example, Sincerely, Sincerely yours, Respectfully yours, or Yours truly. Leave four to five blank lines for the written signature and begin the keyed name and title on the fifth or sixth line below the complimentary close. Start at the center line for modified block style or at the left margin for block style. Key the name and title of the person sending the letter. Long titles may be placed on a second line under the name. Key the reference initials. Start at the left margin regardless of style. Key either the initials of just the preparer or the initials of the writer and the initials of the preparer. Use either capital or small letters. If two sets of initials are used, use a colon to separate capitalized initials and a slash to separate lowercased initials, for example, LMS:WHB or Ims/whb. Some agencies use capital initials for the writer, lowercase initials for the preparer, and a colon to separate the two sets of initials. • Leave neat, even margins at both sides of the paper. Margins should be wide enough to be attractive, but not too wide as to distort. GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 241 BUSINESS AND ACCOUNTING SKILLS 241 | 14/06/2023 10:30

242 CHAPTER 5 293 التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 242 SUMMARY All letters should be proofread before the sender receives them for signature. Make sure that all words are spelled correctly, and that complete sentences and correct punctuation are used. Use the spelling and grammar checks available on most word-processing programs. In most agencies, computers and word-processing software are used to prepare letters, so it is easy to correct errors on the computer screen prior to printing a hard copy of a letter. Technology Many health care agencies have standard form letters saved in a computer database or embedded in their medical office software. When a letter is needed for a specific purpose, such as a letter of appointment, the letter of appointment form letter is retrieved. The patient's name and personal information are keyed into the form letter. If the same letter must be sent to a large group of people, the mailmerge feature (found on most word-processing programs) can be used to create a large number of personalized letters at one time. checkpoint 1. List four types of letters that you may be required to prepare. 2. What is included in the body of a letter? 5:6 COMPLETING INSURANCE FORMS Because many patients rely on insurance companies to pay medical and dental expenses, completing insurance forms may be a part of the duties of the medical assistant. To obtain prompt payment from the companies, you must complete the forms correctly. Information regarding a patient's insurance coverage is essential. Such information is usually obtained on the patient's first visit to the agency. The information is usually recorded on the patient information form, in a computer database, or in the patient's EHR. In addition, most agencies make a copy of the front and back of a patient's insurance card and place the copy in the patient's file or in the patient's EHR. It is essential that all names, addresses, and contract numbers be correct. Double-check this information as it is being recorded. It is also wise to check each time the patient visits the health care agency that their coverage has not changed. If a patient wishes to file an insurance claim, make sure that they have completed any parts of the form that they are required to complete. Also make sure that the patient has signed the form wherever their signature is required. If the patient is a dependent, such as a spouse or older child, it is also necessary to obtain the signature of the person to whom the insurance contract has been issued. This person is referred to as the insured. 14/06/2023 10:30

Confidential medical information cannot be released unless a patient signs an authorization to release information to insurance companies. Because most agencies now complete insurance forms on a computer and file the claims electronically, the patient and the insured usually sign an "Authorization to Release Information and Assign Benefits" form. This form is kept in the patient's file and the insurance form is marked "patient's signature on file". In some agencies, the form is scanned into the computer and filed electronically with the insurance form or is part of the patient's EHR. CODING INSURANCE FORMS Technology Many insurance forms have two parts that require codes: diagnosis and procedures/services. Alphanumeric (letters and numbers) codes are used to identify information in a uniform and standard manner. Most insurance companies use computers to process claims, so the alphanumerical codes must be accurate. Use of an incorrect code can lead to rejection or delayed payment of a claim. The World Health Organization (WHO) has developed a coding system for diagnoses to aid in tracking the presence of the disease, maintaining morbidity (affected with disease) and mortality (causing death) statistics, and creating an international database for identifying disease. This coding system is known as the International Classification of Diseases (ICD). In Saudi Arabia, the 10th revision of the International Classification of Diseases, Australian Modification (ICD-10-AM) is used for diagnosis coding and the Australian Classification of Health Interventions (ACHI) for inpatient procedure reporting. The diagnosis is the identification of the patient's disease or condition. If a patient is diagnosed as having more than one condition, the most important diagnosis and its corresponding ICD-10-AM code are listed first. Other diagnoses and their ICD-10-AM codes follow in order of importance. This coding method is very specific for each disease or condition. The categories begin with a letter. Each level of division is a subcategory. Codes may be three, four, five, six, or seven digits. For example, the category S42 represents a fracture of the shoulder and upper arm. The code S42.2 represents a fracture of the upper end of the humerus. The code S42.20 represents an unspecified fracture of the upper end of the humerus. The sixth digit represents left or right. Therefore, S42.201 represents an unspecified fracture of the upper end of the right humerus. The seventh digit allows for more specificity. The code S42.201A represents an unspecified fracture of the upper end of the right humerus, initial encounter for a closed fracture. On the other hand, the code S42.201B indicates an unspecified fracture of the upper end of the right humerus, initial encounter for an open fracture. If there are more than three digits of a code, a period separates the third digit from the fourth digit. Every diagnosis must be coded to the highest level of specificity or the claim will وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 243 BUSINESS AND ACCOUNTING SKILLS 243 | 14/06/2023 10:30

و244 التعليم Ministry of Education 2024-1446 CHAPTER 5 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 244 be rejected. Therefore, it is important to use as many digits as possible with each diagnosis. It is important to use the latest edition of the book or computer software programs to be sure that the codes are accurate and current. Each procedure or service is assigned a five-digit code without decimal points or periods. Modifiers are used to further explain or to change the meaning of a code and are separated from the code by a dash. For example, the code 44950 indicates an appendectomy, or surgical removal of the appendix. Usually, this is the only code required. However, if the appendectomy was very complex and involved much more time or care than is normally required, the modifier -22 is added to the CPT code for a correct code of 44950-22. To find a diagnosis in the code book, look up the noun or main term in the alphabetical index. For example, look up hysterectomy for a diagnosis of subtotal hysterectomy. Use the code number in the alphabetical index to find the exact ICD-10-AM number in the tabular list for a subtotal hysterectomy. Most computer programs will start with the noun or the three-digit category. When the noun or three-digit code is keyed into the computer, a list appears with subheadings and complete codes. Examples of the ICD-10-AM codes for classification of diseases of the appendix are shown in Table 5–2. Code Disease Acute appendicitis Acute appendicitis with generalized peritonitis: Without abscess With peritoneal abscess K35 K35.2 K35.20 K35.21 K35.3 K35.30 K35.31 K35.32 K35.33 K35.8 K35.80 K35.89 Other acute appendicitis: K35.890 Without perforation or gangrene K35.891 Without perforation, with gangrene Acute appendicitis with localized peritonitis: Without perforation or gangrene With gangrene but no perforation With perforation but no abscess With perforation and abscess Other and unspecified acute appendicitis Unspecified acute appendicitis TABLE 5-2 Sample ICD-10-AM codes. COMPLETING INSURANCE CLAIMS Some general rules that apply to completing insurance forms are as follows: Make sure that you are using the correct form. 14/06/2023 10:30

• Read the form thoroughly or review it on a computer to be sure you understand what is required. • Check to be sure that the patient has completed the proper areas. Make sure their signature appears in all required spaces. If you are using a computer program to generate the form, make sure the patient and insured have signed an “Authorization to Release Information and Assign Benefits" form. This is often kept in the patient's file or in their electronic health record. Double-check for accuracy all names, addresses, and contract numbers listed on the form. Policy numbers or contract numbers frequently include a letter or series of letters. Make sure that these numbers are accurate and appear on the form in the proper places. • Use correct codes, if codes are required. On most forms, numerical codes are used for place of services. Numerical codes are also usually used to describe type of service. • Answer all questions on the form thoroughly and list specific information. For example, instead of putting "laboratory tests", list the tests that have been performed. Standard abbreviations are allowed on most forms. Ensure the accuracy of all abbreviations used. Do not use any periods with abbreviations. Make sure the amounts charged are accurately listed. Double- check all arithmetic. Math • Make sure the physician or other authorized person has signed the form in the required areas. • Note the boxed area for assignment. If the physician or agency will accept the amount allowed by the insurance company as payment in full, this is marked “yes”; if not, it is marked “no”. The form is generally copied or printed, and a copy is placed in the patient's file, or is included in their EHR. Technology • Recheck the entire form before sending electronically or mailing. In many agencies, computers programmed to complete standard insurance claim forms are used. Information for the insurance claim is entered into the computer. The computer then prints the information in the proper areas on the insurance form. The form can be printed and mailed, but many agencies now file insurance forms electronically on a secure modem. Electronic filing results in faster processing and payment of the claim. These programs are easy to use and save a great deal of time when processing insurance forms. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 245 BUSINESS AND ACCOUNTING SKILLS 245 | 14/06/2023 10:30

Pul 246 CHAPTER 5 Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 246 checkpoint 1. What organization developed a coding system for coding diagnoses? 2. When completing an insurance form, you only need to include brief summary information. True or false? 5:7 MAINTAINING A BOOKKEEPING SYSTEM Most facilities and offices are moving to electronic bookkeeping, but some still use the pegboard system. Both systems use the same concepts to track cash flow. PEGBOARD SYSTEM The pegboard system is also called a "write-it-once" system. Various records are noted simultaneously. The pegboard system usually encompasses the following series of records: • • Day sheet (or daily journal): This is a daily record of all patients seen, all charges incurred, and all payments received (Figure 5-12). Each day sheet also provides a "Total" column, which can be used for bank deposit slips; a business analysis summary; a section for daily and monthly account totals; a "Proof of posting" section for verifying that account totals are accurate; and a section to record accounts receivable, or total amounts owed by patients. When a month's supply of day sheets is compiled in one folder, a monthly record of all business is available. Statement-receipt record: This contains information on past balance due, charges for treatment, payment received, and current balance. Many slips also have a space to note the patient's next appointment. When complete, the statement-receipt can be given to the patient to provide a record of payment or of balance due. In some agencies, another version of this record is being used. This version is usually a three-layer form that notes all the previous information as well as specific services and corresponding insurance code numbers. Called a communication form, or a superbill, this version serves as a statement for the insurance company. One copy can be retained by the agency; the second copy can be sent to the insurance company (or attached to an insurance form) to serve as a claim form; and the third copy can be given to the patient to serve as a payment receipt, a record of treatment or services, a bill for the balance due on the account, and an appointment card, if another appointment is scheduled. 14/06/2023 10:30

DATE REFERENCE COLD TOTAL PLUS COL A TOTAL SUBTOTAL LESS COLS. B-1 & B-2 MUST EQUAL COL.C RECORD OF DEPOSITS Office Hosp. Labor- Diag- visits visits atory nostic BUSINESS ANALYSIS SUMMARIES (OPTIONAL) DAY SHEET (RECORD OF CHARGES AND RECEIPTS) PAGE NO- OF DATE DATE CREDITS DESCRIPTION CHARGES BALANCE PYMNTS. ADJ PREVIOUS BALANCE RECEIPT NAME NUMBER CASHI TOTALS THIS PAGE PREVIOUS PAGE MONTH-TO-DATE COL PROVE OF POSTING ACCOUNTS RECEIVABLE CONTROL PREVIOUS DAY'S TOTAL PLUS COL. A SUBTOTAL LES COLS. B-17 B-2 TOTAL ACCTS. REC. PREPARED TOTAL CASH ACCOUNTS RECEIVABLE CONTROL ACCTS. REC. 1ST OF MONTH PLUS COL. A MO TO DATE SUBTOTAL LESS COLS. B-1 & B-2 MO. TO DATE TOTAL ACCTS. REC TOTAL CARD TOTAL DEPOSIT CASH PAID OUT CASH CONTROL Beginning Cash On Hand Receipts Today (Col. B-1) Total Less Paid Outs Less Bank Deposit Closing Cash On Hand FIGURE 5-12 The day sheet provides a daily record of patients seen, charges incurred, and payments received. • • Charge slip: On some pegboard systems, these are a part of the statement-receipt record. When the patient arrives at the agency, their name is entered at the top. This section of the record is torn off the statement-receipt and attached to the patient's file. The physician or other authorized individual then notes the treatments and charges on this slip while treating the patient. The slip is given back to the receptionist, who can then use it to post charges. Ledger card: This is a total record of care provided to a patient. It is also a financial record of the patient's account. A brief description of services, charges, payments made, and current balance due is noted on the card. In some agencies, copies of the ledger cards are used in place of separate bills. The ledger card is copied and mailed to the patient or sent as an e-mail to provide a monthly statement. In addition to recording patients' visits and charges, the pegboard system is also used to record payments received. One example is an insurance company check for payment for services. The same steps are followed, but in place of a treatment, "ROA", for "received on account," is usually noted under the description. Balances are then determined, and all information is simultaneously noted on the day sheet and ledger card. A receipt may be mailed or sent electronically to the patient. Many insurance companies have contracts with health care providers that specify amounts that will be paid for services. When the insurance company sends payment, it usually sends an "Explanation of Benefits" وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 247 BUSINESS AND ACCOUNTING SKILLS 247 | 14/06/2023 10:30

و298 التعليم Ministry of Education 2024-1446 CHAPTER 5 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 248 form. This form lists the amount charged by the health care provider, the negotiated or allowed amount according to the contract, the amount the insurance company pays, and the amount of money owed by the patient. If the negotiated or allowed amount is less than the charged amount, an adjustment must be made to the patient's account. At the end of a business day, the day sheet provides a total record of all charges and payments and a method of checking accounts. Daily totals are obtained by adding the amounts of each column on the day sheet. The accuracy of the records can be checked immediately. Because a series of records is recorded at one time, it is important for the recorder to use a ballpoint pen and print neatly while pressing hard enough for all copies to record. If an error is made, it must be lined out neatly. Neither erasers nor correction fluid should be used because these are financial records that may be audited for tax or legal purposes. If a major error is made, it may be best to void the statement-receipt record and start a new record. Neatness and accuracy are essential when using the pegboard system. These are bookkeeping records; therefore, they must be stored for reference. Special folders can be purchased for this purpose. FINANCIAL ACCOUNTING SYSTEMS Most health care facilities use computer bookkeeping systems. There are many types of software available, but most provide the same basic functions. Most systems begin with the creation of a patient's account history or a computerized ledger card. Information including the name and address of the patient, the person responsible for the account, family members in the account, and insurance information is entered for each patient. These patient demographics form the database for the system. ICD-10-AM codes used in the agency are also programmed into the computer, together with a description of the codes and the fees charged for each. Most software is programmed to indicate a source of payment. When a patient receives a service, the patient's account history is retrieved. Information about the service is entered on a daily transaction screen (Figure 5-13). When the correct codes are entered, the software automatically calculates the current balance by using the past balance in the account history and adding it to the new charges. If payment is made, the software deducts the payment and calculates the new balance. The account history or computerized ledger card is updated automatically as entries are made. Printed copies of the account can be given to the patient or electronic copies can be sent to the patient to show all charges, payments made, and the current balance due. In addition, the account history can be used for billing patients at regular intervals. In addition to handling patient accounts, bookkeeping software will also create a daily journal. This provides a financial record showing patients seen, services provided, charges, payments made, and outstanding balances. 14/06/2023 10:30

Messages- Patient and Provider INFORMATION Patient Name Relationship Voucher Number INSURANCE INFORMATION Covered by Insurance Plan Covering Treatment_ Starting Balance SAR Account Number Provider Number Treatment Date Service Place Last Entered Diagnosis Description is: TREATMENT AND PAYMENT INFORMATION Proc. Code Description Charge Receipt Primary Diag. Suffix Totals New Balance E - Edit, A- Abandon, S - Save, H - Save/Hold, F - Finished F1-New F2-Daily F3-Report F4-Update F5-Post F6-Pull F7-Mail F8-Recall F9-Notes FIGURE 5-13 A daily transactions entry screen allows the health care provider to enter information about a patient's treatments and maintain the patient's account. Most software will generate a deposit slip created from the totals entered as payment is made. Most electronic billing systems are easy to use. The software guides the user through each step of entering financial information by providing directions or asking the user questions. However, the health care team member must still understand the basic principles of financial management used in the manual bookkeeping method to use the computerized program. In addition, safeguards must be in place when this type of system is used. Most agencies use password protection so only authorized individuals are allowed access to the financial information. In addition, all systems should be programmed to record deleted transactions to prevent someone from deleting a transaction and stealing the money. A final important point is to make sure frequent backups are made of all information in case of computer failure. checkpoint 1. What is a day sheet? 2. What does "ROA” stand for? وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 249 BUSINESS AND ACCOUNTING SKILLS 249 | 14/06/2023 10:30

ليد Today's Research Tomorrow's Health Care Bionic Peepers? Retinitis pigmentosa (Figure 5-14) is the name given to a group of inherited eye diseases that cause a gradual loss of vision leading to blindness. These diseases affect the retina, the nerve sensitive layer of the eye that contains the photoreceptor cells called cones and rods. Cones are sensitive to color and are used mainly to provide vision when it is light. Rod cells are used for vision in dark or dimly lit environments and to capture images to provide peripheral or side vision. Retinitis pigmentosa causes a gradual deterioration of these. cells, eventually leading to blindness. This disease is usually diagnosed in adolescents and young adults, and most people with the condition are blind by age 40. Researchers have helped individuals with retinitis pigmentosa see some images by creating an artificial retina. The first artificial retina contained 16 electrodes and was implanted in 6 patients. The patients were able to distinguish some light patterns and locate some objects. This success led to the development of an Argus II implant, which contains 60 electrodes. The system uses glasses with a video camera to capture the scene, processes the information on a computer. the size of a wallet that is worn around the patient's neck or on a belt, and sends a signal to the electrodes implanted in the retina. The electrodes then stimulate the photoreceptors to transmit the signal to the brain through the optic nerve to create the images of sight. It was implanted in 30 patients for the first clinical trials that ran for almost 4 years. The device did not restore normal vision, but the patients were able to see colors, recognize large letters, and locate objects. Two patients were even able to read short sentences. Research continues to increase the number of electrodes in the implant to allow patients to interpret more images. Now major research is being directed toward creating a retinal implant using a conductive polymer material that is covered with a semiconducting polymer, which bends and flexes like normal tissues when it is implanted in the eye. The semiconducting polymer absorbs photons when light enters the eye and directs electrical signals to surviving retinal neurons, which then send the impulses to the brain for interpretation as vision. This implant does not need an external camera or computer because it acts like healthy retinal tissue. Initial trials are being conducted to determine how effective the implant is in restoring vision. Normal vision Vision with retinitis pigmentosa Healthy retina Retina with retinitis pigmentosa FIGURE 5-14 Retinitis pigmentosa. Case Study Investigation Conclusion When Khalid and Fahad are scheduled to cross-train in scheduling and filing, what skills will they need? What are some of the filing tips Khalid would tell Fahad as he is training him? What points will Khalid need to be aware of when he schedules patients and takes messages? 250 CHAPTER 5 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 250 14/06/2023 10:30