APPENDIX B: Templates for create your

own practice activities

Unit 1: Chapter 2, Question 1Template for Creating a Policy and Procedure

Write a policy and procedure for the use of advanced beneficiary notices (ABNs).

Name of policy: Advanced Beneficiary Notices

Department: Medical Administration

Date enacted: Jan. 2012 Revised:

Purpose of policy: The purpose of this policy and procedure is to guide the administrative personnel as to when to have a patient sign an ABN.

Procedure:1. Recognize when a patient needs to sign an ABN.

2. Review the ABN with the patient.

3.

4.

Attachments:

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Unit 1: Chapter 2, Question 2Template for Creating a Policy and Procedure

Write a policy and procedure for when to use an MSP (Medicare as a secondary payer) questionnaire.

Name of policy: Completing the MSP Questionnaire

Department: Medical Administration

Date enacted: Jan. 2012 Revised:

Purpose of policy: The purpose of this policy and procedure is to guide the frontline medical administrative personnel as well as others in this role as to when to complete a MSP questionnaire.

Procedure: 1. Identify situations in which an MSP form needs to be completed:

a.

b.

c.

2.

etc.

Attachments:

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Unit 1: Chapter 2, Question 3Template for Creating a Policy and Procedure

Write a policy and procedure for triaging or screening phone calls.

Name of policy: Triaging Telephone Calls

Department: Medical Administration

Date enacted: Jan. 2012 Revised:

Purpose of Policy: The purpose of this policy is to establish guidelines for triaging phone calls to the correct personnel in the health care facility.

Procedure:1. Identify the type of call.

2.

3.

etc.

Attachments:

Appendix B: TemplaTes for creaTe your own pracTice acTiviTies 361

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Unit 1: Chapter 2, Question 4Template for Creating a Policy and Procedure

Write a policy and procedure for collecting copayments.

Name of policy: Collecting Copayments

Department: Medical Administration

Date enacted: Jan. 2012 Revised:

Purpose of policy: The purpose of this policy and procedure is to establish a consistent policy and procedure to collect copayments at the time of visit.

Procedure:1. Identify the patient and the patient’s insurance.

2.

3.

etc.

Attachments:

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Unit 2: Chapter 4, Question 1Template for Creating a Policy and Procedure

Write a policy and procedure for the hiring process.

Name of policy: The Hiring Process

Department: Human Resources

Date enacted: 2012 Revised:

Purpose of policy: To have a uniform policy in the hiring process that incorporates the scope of practice for all personnel and includes all related licensing, certification, and knowledge of applicable regulations.

Procedure:1. Determine what job openings the health care facility has.

2. Know the responsibilities for each position.

3.

4.

5.

Attachments: Job description

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Unit 2: Chapter 4, Question 2Template for Creating a Policy and Procedure

Write a policy and procedure for conducting a background check.

Name of policy: Conducting a Background Check

Department: Human Resources

Date enacted: 2012 Revised:

Purpose of policy: To have a uniform procedure in place for conducting a background check on affected personnel.

Procedure:1. Complete the hiring process.

2. Offer applicant the position, indicating that employment will depend on results from a background check.

3. Give the applicant the background check form to complete, with instructions.

4.

5.

Attachments: Background check form

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Appendix B: TemplaTes for creaTe your own pracTice acTiviTies 365

Unit 2: Chapter 4, Question 3Template for Creating a Policy and Procedure

Write a policy and procedure for terminating employment

Name of policy: Termination of Employment

Department: Human Resources

Date enacted: 2012 Revised:

Purpose of policy: This policy is to follow a uniform procedure when an employee is terminated from a position, ensuring consistency with documentation.

Procedure:1. Perform an exit interview.

2.

3.

4.

Attachments:

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Unit 2: Chapter 4, Question 4Template for Creating an Employment Advertisement

Write an employment advertisement to place in the classifieds of the local newspaper for a medical assistant. Include the role, responsibilities, education, and salary.

Employment job type: Medical Assistant

Practice name:

Full-time or part-time position:

Hours:

Qualifications:

Other points:

Respond to you (the manager):

Telephone/fax number:

E-mail:

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Appendix B: TemplaTes for creaTe your own pracTice acTiviTies 367

Unit 2: Chapter 4, Question 5Template for Creating Job Descriptions

Write a job description for the medical assistant for your practice. Information about this job is located on the Department of Labor’s Occupational Outlook Handbook website

(http://stats.bls.gov/oco). (See website activities.)

Job title:

Department:

Reports to:

Qualifications (education, licenses, certifications, etc.):

Summary of responsibilities:

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

etc.

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Unit 2: Chapter 4, Question 6Template for Writing an Offer Letter

Write an offer letter for a prospective hire.

Date:

Dear _________,

Sincerely,

Office Manager

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Unit 3: Chapter 6, Question 1Template for Creating a Policy and Procedure

Write a policy and procedure for determining eligibility for charity care.

Name of policy: Determining Eligibility for Charity Care

Departments: Billing and Insurance

Date enacted: 2007 Revised: 2012

Purpose of policy: This policy will determine who meets the requirements for charity care.

Procedure:1. Patient makes an appointment.

2.

3.

4.

Attachments:

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Unit 3: Chapter 6, Question 2Template for Creating a Policy and Procedure

Write a policy and procedure for taking action based on the aging report.

Name of policy: Collection activity action

Departments: Billing and Insurance

Date enacted: 2007 Revised: 2012

Purpose of policy: This policy outlines the steps to take in the process of collection based on the accounts aging report.

Procedure:1. At the 30-day mark . . .

2. At the 60-day mark . . .

3.

4.

Attachments: Sample letters

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Appendix B: TemplaTes for creaTe your own pracTice acTiviTies 371

Unit 3: Chapter 6, Question 3Template for Creating a Policy and Procedure

Write a policy and procedure for whose responsibility it is for collection activities.

Name of policy:

Department:

Date enacted: Revised:

Purpose of policy:

Procedure:

1.

2.

3.

etc.

Attachments:

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Unit 3: Chapter 6, Question 4Template for Developing a Teaching Session or In-Service Training

You want to teach your new employees about accounts aging reports and collection activities. Plan a teaching session:

• Create an outline of content to be discussed.

• Create a sign-in sheet.

• Review the policies and procedures you created for your practice.

Topic:

Departments or positions included in session:

Outline:

How this topic pertains to your department or job title:

Why it needs to be discussed today:

Brief description of the history of this topic:

Situations that apply to this setting:

Discussions:

Questions and answers:

Handouts to be distributed:

1. Sign-in sheet to be created, including date and topic.

2.

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Unit 4: Chapter 8, Question 1Template for Creating a Policy and Procedure

Write a policy and procedure for developing a consistent review of a medical record.

Name of policy: Reviewing Medical Records

Department: Medical Records

Date enacted: 2/14/2012 Revised:

Purpose of policy: To create a consistent procedure in reviewing the medical record.

Procedure: Each medical record component needs to be reviewed for completeness. Each medical record must contain:1. Patient name

Attachments: Approved by: Date:

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Unit 4: Chapter 8, Question 2Template for Creating a Policy and Procedure

Write a policy and procedure for ensuring the consistency within a medical record. Include documenting, necessary requirements, and organization.

Name of policy:

Department :

Date enacted: Revised:

Purpose of policy:

Procedure:

1.

2.

3.

etc.

Attachments:

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Unit 4: Chapter 8, Question 3Template for Developing a Teaching Session or In-Service Training

You have found when auditing a medical record that it is incomplete. Prepare a teaching session on what goes in the medical record and how to ensure its consistency. Create an outline, a sign-in sheet, and a handout.

Topic:

Departments or positions included in session:

Outline:

How this topic pertains to your department or job title:

Why it needs to be discussed today:

Brief description of the history of this topic:

Situations that apply to this setting:

Discussions:

Questions and answers:

Handouts to be distributed:

1. Sign-in sheet to be created, including date and topic.

2.

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Unit 4: Chapter 8, Question 4Template for Creating a Policy and Procedure

Write a policy and procedure for maintaining consistency in a medical record with regards to an abbreviation policy, including approved abbreviations.

Name of policy:

Department:

Date enacted: Revised:

Purpose of policy:

Procedure:

1.

2.

3.

etc.

Attachments:

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Unit 4: Chapter 8, Question 5Template for Developing a Teaching Session or In-Service Training

You have found when auditing a medical record that the use of abbreviations is inconsistent and impacting patient care negatively. Prepare a teaching session on

how to ensure their consistency. Create an outline, a sign-in sheet, and a handout.

Topic:

Departments or positions included in session:

Outline:

How this topic pertains to your department or job title:

Why it needs to be discussed today:

Brief description of the history of this topic:

Situations that apply to this setting:

Discussions:

Questions and answers:

Handouts to be distributed:

1. Sign-in sheet to be created, including date and topic.

2.

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Unit 5: Chapter 10, Question 1Template for Creating a Policy and Procedure

Write a policy and procedure for auditing a hospital record.

Name of policy: Auditing the Chart of a Hospitalized Patient

Department: Management

Date enacted: Revised:

Purpose of policy: Ensure compliance and continuity in the chart of a hospitalized patient.

Procedure:1. Review chart components for the patient’s name, record number, and date consistency.

2. Obtain the claim form to compare documentation to the claim form.

3.

4.

Attachments:

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Unit 5: Chapter 10, Question 2Template for Creating a Policy and Procedure

Write a policy and procedure for auditing a surgical chart.

Name of policy: Auditing the Chart of the Patient Who Has Had Surgery

Department: Date enacted: Revised:

Purpose of policy: To review the medical chart for compliance and consistency.

Procedure:1. Review the chart for consistency in patient name, medical record number, and dates.

2. Preoperative review:

3.

4.

Attachments:

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Unit 5: Chapter 10, Question 3Template for Developing a Teaching Session or In-Service Training

Write an in-service training session to teach your billing department how to recognize situations and prevent denials by an insurance company.

Topic:

Departments or positions included in session:

Outline:

How this topic pertains to your department or job title:

Why it needs to be discussed today:

Brief description of the history of this topic:

Situations that apply to this setting:

Discussions:

Questions and answers:

Handouts to be distributed:

1. Sign-in sheet to be created, including date and topic.

2.

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Unit 5: Chapter 10, Question 4Template for Creating an Employment Advertisement

Write an employment advertisement to place in the classifieds of the local newspaper for an on-site medical auditor. Include the role, responsibilities, education, and salary.

Employment job type: Medical Auditor

Practice name:

Full-time or part-time position:

Hours:

Qualifications:

Other points:

Respond to you (the manager):

Telephone/fax number:

E-mail:

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Unit 6: Chapter 12, Question 1Template for Creating a Policy and Procedure

Write a policy and procedure for employee exposure control for compliance with OSHA standards.

Name of policy:

Department:

Date enacted: Revised:

Purpose of policy:

Procedure:

1.

2.

3.

etc.

Attachments:

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Unit 6: Chapter 12, Question 2Template for Developing a Teaching Session or In-Service Training

Perform in-service training for a medical assistant to cover the OSHA exposure control requirements. Include clinical and administrative standards for your state.

Topic:

Departments or positions included in session:

Outline:

How this topic pertains to your department or job title:

Why it needs to be discussed today:

Brief description of the history of this topic:

Situations that apply to this setting:

Discussions:

Questions and answers:

Handouts to be distributed:

1. Sign-in sheet to be created, including date and topic.

2.

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Unit 6: Chapter 12, Question 3Template for Creating a Policy and Procedure

Write a policy and procedure for effective communication when recording critical test results.

Name of Policy:

Department:

Date enacted: Revised:

Purpose of policy:

Procedure:

1.

2.

3.

etc.

Attachments:

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Appendix B: TemplaTes for creaTe your own pracTice acTiviTies 385

Unit 6: Chapter 12, Question 4Template for Developing a Teaching Session or In-Service Training

Perform in-service training for all employees on effective communication when recording critical test results.

Topic:

Departments or positions included in session:

Outline:

How this topic pertains to your department or job title:

Why it needs to be discussed today:

Brief description of the history of this topic:

Situations that apply to this setting:

Discussions:

Questions and answers:

Handouts to be distributed:

1. Sign-in sheet to be created, including date and topic.

2.

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Name of policy:

Department:

Date enacted: Revised:

Purpose of policy:

Procedure:

1.

2.

3.

etc.

Attachments:

Unit 6: Chapter 12, Question 5Template for Creating a Policy and Procedure

Write a policy and procedure for developing an action plan after a sentinel event (such as a patient falling).

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Unit 6: Chapter 12, Question 6Template for Creating an Exposure Plan

Write an exposure plan for protecting clinical employees from blood-borne pathogens. Include information necessary to keep employees safe from patient’s blood or body fluids.

Exposure Plan

Prevention techniques:

Engineering controls:

Workplace controls:

Additional comments:

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Unit 7: Chapter 14, Question 2Template for Market Analysis Survey

Write a close-ended market analysis survey about patients’ preferences when it comes to health care. Include at least 10 items that you may ask with regards to your facility that will help you determine the need for your services in the area.

Unit 7: Chapter 14, Question 1Template for Patient Survey

Write an open-ended patient survey about your office. Include at least 10 items you may ask a patient with regards to your facility. Also, include the time frame in which you will administer the patient survey.

Patient Survey

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Market Analysis Questionnaire Create questions that have “Yes” or “No” answers.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

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Unit 7: Chapter 14, Question 3Template for a Marketing Advertisement

Write an advertisement for a health clinic that offers a free health screening. Include the target audience, advertising time frame, and amount of time.

Advertising type:

Practice name:

Address:

Date:

Time frame:

Target audience:

Advertisement:

Other points:

Respond to you (the manager):

Telephone/fax number:

E-mail:

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Unit 7: Chapter 14, Question 4Template for an Advertising Schedule

Write a schedule for when an advertisement needs to begin and when it should end according to the schedule of the event.

Monday Tuesday Wednesday Thursday Friday

Week 1 Monday Tuesday Wednesday Thursday Friday Notes Due

Week 2 Monday Tuesday Wednesday Thursday Friday

Week 3 Monday Tuesday Wednesday Thursday Friday

Week 4 Monday Tuesday Wednesday Thursday Friday

Week 5 Monday Tuesday Wednesday Thursday Friday

Week 6 Monday Tuesday Wednesday Thursday Friday

Week 7 Monday Tuesday Wednesday Thursday Friday

Week 8 Monday Tuesday Wednesday Thursday Friday

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Appendix B: TemplaTes for creaTe your own pracTice acTiviTies 391

Extra TemplatesTemplate for Creating Policies and Procedures

Name of Policy:

Department:

Date enacted: Revised:

Purpose of policy:

Procedure:

1.

2.

3.

etc.

Attachments:

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392 Appendix B: TemplaTes for creaTe your own pracTice acTiviTies

Template for Creating Job Descriptions

Job title:

Department:

Reports to:

Qualifications (education, licenses, certifications, etc.):

Summary of responsibilities:

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

etc.

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Appendix B: TemplaTes for creaTe your own pracTice acTiviTies 393

Template for Creating an Employment Advertisement

Employment job type:

Practice name:

Full-time or part-time position:

Hours:

Qualifications:

Other points:

Respond to you (the manager):

Telephone/fax number:

E-mail:

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Template for Writing an Offer Letter

Date:

Dear ,

Sincerely,

Office Manager

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Appendix B: TemplaTes for creaTe your own pracTice acTiviTies 395

Template for Developing a Teaching Session or In-Service Training

Topic:

Departments or positions included in session:

Outline

How this topic pertains to your department or job title

Why it needs to be discussed today

Brief description of the history of this topic

Situations that apply to this setting

Discussions

Questions and answers

Handouts to be distributed:1. Sign-in sheet to be created, including date and topic

2.

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Template of Creating an Exposure Plan

Exposure Plan

Prevention techniques:

Engineering controls:

Workplace controls:

Additional comments:

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Appendix B: TemplaTes for creaTe your own pracTice acTiviTies 397

Template for Patient Survey

Patient Survey

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

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Template for Market Analysis Survey

Market Analysis Questionnaire Create questions that can have “Yes” or “no” answers.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

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Template for a Marketing Advertisement

Advertising type:

Practice name:

Address:

Date:

Time frame:

Target audience:

Advertisement:

Other points:

Respond to you (the manager):

Telephone/fax number:

E-mail:

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Template for an Advertising Schedule

Monday Tuesday Wednesday Thursday Friday

Week 1 Monday Tuesday Wednesday Thursday Friday Notes Due

Week 2 Monday Tuesday Wednesday Thursday Friday

Week 3 Monday Tuesday Wednesday Thursday Friday

Week 4 Monday Tuesday Wednesday Thursday Friday

Week 5 Monday Tuesday Wednesday Thursday Friday

Week 6 Monday Tuesday Wednesday Thursday Friday

Week 7 Monday Tuesday Wednesday Thursday Friday

Week 8 Monday Tuesday Wednesday Thursday Friday

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