VA’s of the Future 1

VA’s of the Future 2

Medical Virtual Assistant Toolkit

Table of Contents

What is a Medical Virtual Assistant?

● Introduction to Medical Virtual Assistant
● Pros and Cons of Being a Medical Virtual Assistant
● Skills to have and Skills that you need to Develop
● Must Have tools for Medical Virtual Assistants
● Types of Medical Virtual Assistant Careers
● Common Responsibilities as a Medical Virtual Assistant
● Minimum Skills Required to be a Medical Virtual Assistant

CORE
● Core
● What tools you will need
● Identify your Skills
● Core Skills

Core Skills 1: Common Medical Terminologies

● Common Terms for Patient Status
● Abbreviations and Acronyms
● Diseases and Condition
● Prefixes and Suffixes
● Procedures and Tests
● Tools and Equipment
● Charting Terminologies

Core Skills 2: Establishing Professional Relationship with Medical Team and Patients
● Benefits of Developing and Maintaining Relationships
● Creating and Maintaining Relationships
● How to Build Good Work Relationships

Core Skills 3: Phone Etiquette

● What is Phone Etiquette and its Importance
● Top 10 Phone Etiquette
● Customer Service Etiquette

Core Skills 4: HIPAA

● What is HIPAA
● Introduction to HIPAA
● What is HIPAA Compliance
● Protected Health Information
● Who Needs to be HIPPA Compliant
● HIPAA Business Associates

Core Skills 5: Appointments and Schedule

● How to Schedule and Cancel Schedule using PF
● How to Schedule and Cancel Schedule using Athena
● How to Schedule and Cancel Schedule using Dr. Chrono

Core Skills 6: Navigating through different EHR/EMR

● Navigating through Practice Fusion
● Navigating through Athena Health
● Navigating through Dr. Chrono

Core Skills 7: Prescriptions

● What is a Prescription
● Parts of a Prescription
● What is Prescription Renewal
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● What is a Prescription Refill

● How to refill a prescription

Core Skills 8: Insurance Verifications and Prior Authorization

● What is Insurance Verifications
● Why is Insurance Verification Important
● How to Verify Medical Insurance Eligibility
● What is Prior Authorization
● Prescription and Medical Prior Authorization
● How to do a Prior Authorization

Core Skills 9: SOAP Notes and Scribing

● What is a SOAP Notes
● How to write a SOAP Notes
● Components of a SOAP Notes
● What is Medical Scribing
● How to be a Successful Medical Scribe
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What is a Medical Virtual Assistant?

● A medical virtual assistant is an administrative assistant who remotely supports their
employer, typically from their home office. While the specific duties of a virtual medical
assistant will vary depending on their employer, they may include scheduling appointments,
handling correspondence, and managing records.
● They are also responsible for communicating with Medical Professionals and Patients.

What are the common tasks and responsibilities of a Medical Virtual Assistant?
The common tasks and Responsibilities are:
1. Medical Scheduling Appointments
One of the essential tasks of an MVA is scheduling appointments. This involves coordinating with
patients, providers, and office staff to ensure everyone can meet at the desired time and place. From
answering phone calls to emails, the whole system’s time management depends on this VA.
2. Maintain Electronic Medical Records
Healthcare virtual assistants can help manage or maintain medical transcriptions through electronic
medical records, the digital versions of patient charts containing information such as diagnostic test
results and treatment plans. Maintaining accurate and up-to-date medical records is essential for
providing quality patient care.
3. Duties Regarding Patient Care
The duties of a medical VA regarding patient care include answering questions and supporting
patients regarding appointments, medications, treatments, insurance verification, dietary restrictions,
and other health-related issues.
4. Responding To Patient Questions
Patients often have questions about their condition, treatment plan, or medications. A medical VA can
provide answers to common inquiries or direct the patient to resources to find more information. For
example, a medical VA can explain how to take medication or what side effects to expect.
5. Taking Notes During Patient Consultations
During a patient consultation, a medical VA takes notes so the provider can focus on the
conversation. After the visit, the VA types the notes and sends them to the provider. This ensures that
important details are remembered and allows the provider to review the messages before writing their
report.
6. Follow-Up Appointments
Following a patient visit, the medical VA schedules any needed follow-up appointments. This may
include arranging lab tests or imaging studies, Prescription refills, Setting up referrals to specialists,
Booking future meetings with the primary care provider.
By handling these details, a medical VA makes it comfortable for patients to follow the track with their
care plan and avoid gaps in care.
7. Data Entering Into A Computer System
The medical VA helps with data entry to keep the medical practice up-to-date. This data can include
patient information, appointments, and insurance information. Therefore, it is essential to be accurate
and timely in your data entry to avoid complications. Electronic record maintenance is another crucial
aspect of data entry, ensuring that patient information is readily available and up-to-date.
8. Handling Correspondence And Billing
This includes staying in touch with patients about appointments, payments, and handling billing
inquiries. Being professional and courteous when dealing with patients and their correspondence is
essential.
9. Time Management Of Meetings And Other Tasks
Time management includes more than scheduling appointments or completing tasks promptly. It also
involves overseeing the daily schedule, meeting the timing of doctors, assigning tasks to different
departments, and monitoring progress. This prioritizes tasks, saves time, and ensures that all
deadlines and projects are completed on time.
10. Processing Insurance Claims
A virtual medical assistant can help with various tasks related to insurance claims processing. For
example, they can contact insurance companies to check on the status of claims, verify coverage
levels, and keep track of payments. They can also help prepare and submit claims, as well as appeal
denied claims.
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Minimum Skills Required to be a Medical Virtual Assistant

1. Typing Skills
To be an efficient healthcare virtual staff, you need to type accurately fast. According to Indeed.com,
most companies looking for virtual assistants require a typing speed of at least 60 words per minute
with 100% accuracy.
1.1. How to Improve Your Typing Skills?
For starters, take advantage of free typing test tools online, such as typingtest.com. Run the
typing test and see what your initial speed is. To improve your typing speed, you can:
Repeatedly do different typing tests from various online tools.
Use the keyboard more. For training purposes, a keyboard with hard keys is more advisable.
For work purposes, though, soft keyboards can lead to higher efficiency. Volunteer to type
emails for an older aunt, start a nightly journal on your laptop or chat more often with your
friends on social media. When chatting, remember to use the proper capitalization to become
part of your second nature when typing work documents.
Remember to use the proper fingers for typing. If you have accustomed to not using the
correct fingers for the right keys on the keyboard, it is high time you learn the correct way of
typing. It may be challenging at first, but you will be able to surpass your maximum typing
speed in time.

2. Word Processing Skills

Working as a remote medical assistant means relying on computer software and online applications.
A high level of proficiency in Microsoft Office applications is expected, along with other word
processing tools.
2.1 Some of the essential software a virtual assistant needs to be able to use is as follows:
● Microsoft Word
● Microsoft Excel
● Google Docs
● Google Sheets
● Google Drive
● Skype, Zoom, or other video conferencing apps – for job application interviews and meetings
once hired.
2.2 How to Improve Your Word Processing Skills
The most experienced virtual assistants have spent years using these applications, and they have
explored the short keys and mastered the most efficient ways of utilizing this software. If you
are not too confident about your proficiency in using these apps, take advantage of the free
online tutorials and training materials for the specific apps. Here are a few:

Microsoft Office
o GCF Global
o Microsoft Training Center
o John Academy – video

Google Docs
o GCF Global
o Google
o Udemy – videos included (needs enrollment)

Google Sheets
o Google
o freeCodeCamp – video
o Coursera

3. Verbal and Written Communication Skills

A virtual healthcare assistant should be able to communicate his messages well both to clients and
work colleagues. He needs to convey ideas, suggestions, and recommendations that add value to his
work or the institution he works with. He should not be hesitant to ask questions and confirm
instructions when needed, and he should be able to employ a positive tone in his correspondence.

Here are some areas where a medical virtual assistant’s communication skills matter:
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● Daily email correspondences

● Chat and collaboration apps with peers and clients
● Online meetings and video conferences
● Organization’s social media pages

3.1 Tips for an Effective Verbal Communication at Work

1. Listen actively. This involves listening to the message and trying to listen for the speaker’s
intent or purpose. Respond appropriately when asked. Use verbal nods to let the speaker
know that you are listening to what he is saying.
2. Understand different communication styles. Some people prefer direct responses, while
others need comprehensive explanations or various examples. Some colleagues might
choose communication via email, while others might like unscheduled but quick video
conference meetings. Learning your co-workers’ preferred communication style can help you
achieve more effective communication skills.
3. Practice positivity. Instead of saying “no,” you can mention what you can do as an alternative.
Instead of saying “I’m not sure” or “I don’t know,” you can say that you will be looking for the
answer. Receiving and giving positive responses to other employees at work can result in a
friendlier atmosphere and encourage open communication.
4. Always stay professional but friendly. While verbal communication is too warm and rigid, you
can find a common ground where these two meet. Always follow proper communication
etiquette (no foul words, no shouting, do not interrupt, etc.), but be friendly with your
messages and tone.

3.2 How to Improve Your Written Communication Skills

1. Practice, practice, and more practice.
2. Read, read, and read some more.
3. Use a proofreading tool such as Grammarly to help you check your written output.
Understand the rule behind each proofreading note so you will not commit the same mistakes
again.
4. Learn from your peers and your superiors. Find time to check how they compose their email
messages or their published articles online.
5. Research. This can help your writing skills in two ways. First, you can research for references
before you start writing your piece. Second, you can also explore online how else to improve
your writing skills.
6. Outline. Sometimes we would come up with lots of ideas streaming at the same time for a
given topic. You can only write them effectively through thought organization, which can be
achieved by creating an outline. Once created, try to stick to the outline and refrain from
branching out.
7. Keep it positive. Always be on the positive side when writing, as your tone reflects your
company’s core values.

4. Computer Proficiency
If you know your apps and online tools, then that’s great. Computer proficiency, however, means you
know your way around computers and the world wide web. You should install new applications, as
you would most likely be asked when you get hired as a virtual assistant. You should know how to
store your login credentials. You should know how to organize your files on your computer so you can
easily pull them up when needed.

Must Have tools for Medical Virtual Assistants

Medical Virtual Assistants (MedVAs) play a crucial role in supporting healthcare professionals and
managing administrative tasks in a virtual environment. Here are some must-have tools and
resources for MedVAs:

Electronic Health Record (EHR) Systems: Familiarize yourself with popular EHR systems like Epic,
Cerner, or Meditech, depending on the healthcare facilities you work with. Proficiency in using EHRs
is essential for managing patient records.

HIPAA-Compliant Software: Ensure that all software and communication tools you use are
compliant with the Health Insurance Portability and Accountability Act (HIPAA) to protect patient
privacy and data security.
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Video Conferencing Platforms: Use reliable video conferencing tools such as Zoom, Microsoft
Teams, Google Meet, or Webex for virtual meetings, telemedicine appointments, and collaborations
with healthcare professionals.

Document Management Software: Invest in document management software like Microsoft Office
365, Google Workspace (formerly G Suite), or document-sharing platforms like Dropbox or Google
Drive to manage and share healthcare documents securely.

Appointment Scheduling Tools: Utilize scheduling tools like Google Calendar or appointment
scheduling software to manage healthcare providers' calendars, schedule appointments, and send
reminders.

Medical Billing and Coding Software: If you're involved in medical billing and coding tasks, consider
using dedicated software like Kareo, AdvancedMD, or other billing solutions to streamline the billing
process.

Dictation and Transcription Tools: Implement dictation and transcription software like Dragon
NaturallySpeaking or Nuance to transcribe medical notes and records accurately.

Telehealth Platforms: Familiarize yourself with telehealth platforms like Doxy.me, SimplePractice, or
Teladoc if you assist with virtual patient consultations.

Medical Terminology Resources: Access medical dictionaries, online resources, or mobile apps to
look up medical terms and abbreviations quickly.

Email and Communication Tools: Maintain professional communication with healthcare providers
and patients using secure email services like ProtonMail, and consider using HIPAA-compliant
messaging platforms.

Telephonic Tools: If you handle phone calls, use a reliable VoIP service like Skype for Business,
RingCentral, or other telephony solutions to make and receive calls remotely.

Qualifications Needed by a Healthcare Virtual Staff

Reliability and Professionalism
If your job role is a healthcare virtual staff, you are expected to perform your tasks and daily
duties. The doctor you work for should be able to rely on you to keep him updated with his
upcoming meetings and appointments. The patients you send emails should trust you to
provide them with the information they are looking for. And you need to perform your
responsibilities on a professional level, always.

Resourcefulness
While training will be conducted for you during your onboarding, not everything can be
discussed before starting the actual work. Find time to get to know the company and the
people you work with beforehand by browsing through your company files and online pages.
Try to refrain from asking questions whose answers are available online.
Accuracy and Efficiency
As a medical virtual assistant, you must provide accurate information to your physicians and
patients. If data entry is part of your tasks, you need to manage data in your EMRs (electronic
medical records) and EHRs (electronic health records) with a top-level accuracy. In the
medical field, a simple clerical error can lead to fatal consequences. While being accurate,
you need to perform all these duties efficiently because part of the reason you were hired is
the time savings you can offer.
Time Management and Being Organized
You are helping doctors manage their time, but how can you do so without managing your
time well? Aside from setting up physician schedules, you might want to create a schedule for
yourself as well. And what better way to manage your time than by being organized? Develop
a naming convention for your files if you are involved with many documents and
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spreadsheets. Organize them in well-labeled folders so you can quickly pull them up when
needed.
Adaptability, Flexibility, and Resiliency
You will be working with other employees who are oceans away, which means you need to be
familiar with their culture and communication styles. Also, your schedule can be very drastic
in the healthcare industry, which should be of little challenge to you if you have flexibility.
A Problem-Solver
Critical thinking can get you miles in any industry. If you notice a potential problem, then
immediately figure way things out within your scope. If the resolution is beyond you, then be
open to talking to your boss about it before things get worse.
Continuous Learning and Trainability
If you want to be an expert virtual healthcare assistant and be a top player in your field, then
challenge yourself to learn new things. First, aim for proficiency for the roles that you perform.
Once satisfied with your expertise on your current duties, expand your portfolio by learning a
new skill. Do not be afraid to make minor mistakes because it is through mistakes that we can
learn.
Proactiveness
When you stumble upon a news article that your doctor can benefit from, let him know. Your
physician forgot to mention a task that you are doing every day; you do it anyway. You finish
your scheduled tasks early; you go to your boss and ask if there are other tasks you can help
with. Do not wait for orders to be assigned to you; you find things to do independently.
Confidence
Confidence is never a problem for seasoned virtual healthcare staff unless you have chronic
stage fright or similar conditions. For beginners though, you need to “fake it till you make it.”
Confidence for neophytes can be compared to acting. During the first few takes, the director
might not like some portions of your acting, but if you practice speaking with confidence, you
will eventually have that applause of acceptance.
Integrity and Self-Discipline
Most companies employing remote workers are now requiring them to install a time tracking
app. If your employer is not asking you to install one, it means that he fully trusts you. Integrity
means “doing the right thing even when no one is looking,” or even when no time tracking app
is monitoring.
Empathy and Patience
We have different communication styles and have different “wrong buttons.” If someone
inadvertently pressed your wrong button, have patience, and let it go. On the other hand, if
you mistakenly said something that may have been offensive to another employee, be
empathic. Try to identify where the other person is coming from and say sorry.
Multitasking and Batching
Multitasking means you are performing multiple tasks at the same time. For example, you are
uploading files to your server, and you know it takes about 2-3 minutes to upload a single
document. While waiting for an upload to complete, you can do your clerical tasks on the side.
Another example is when you take notes while talking to your boss or a patient on the phone.
Batching, on the other hand, is organizing your tasks on a scheduled basis or per batches.
For example, you will be working on data entry on your first hour, email management on your
second hour, digitizing EHRs on your third hour, and so on. Usually, batching is used for
routine tasks because you would not have to finish all your digitizing tasks first since that
might take days or weeks or never (pun intended). Your emails would be sad if that were the
case.
Quick Thinking and Decision Making
In the medical field, there will be a lot of times when you will have to exercise quick thinking
and sound judgment. It is essential that a healthcare virtual staff has this qualification.

Pros and Cons of Being a Medical VA

Becoming a Medical Virtual Assistant (MedVA) can be a rewarding career choice, but like any
profession, it comes with its own set of pros and cons. Here are some of the advantages and
disadvantages of being a MedVA:
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Pros:
Flexibility: MedVAs often have the flexibility to work from home or any location with an internet
connection. This flexibility can be especially appealing for individuals who value work-life balance.

Diverse Work Opportunities: MedVAs can work with a variety of healthcare professionals, including
doctors, dentists, therapists, and more. This diversity allows for a wide range of job opportunities.

Steady Demand: The healthcare industry continually requires administrative support, so there is a
relatively stable demand for MedVAs. This can lead to job security.

Specialization Options: MedVAs can specialize in areas such as medical billing and coding,
telemedicine support, or EHR management, allowing for career growth and advancement.

Lower Overhead Costs: As a virtual assistant, you won't need to invest in a physical office or
commute, which can significantly reduce overhead costs.

Potential for Higher Earnings: Depending on your skills, experience, and specialization, MedVAs
can earn competitive salaries, especially if they offer specialized services.

Cons:
Isolation: Working remotely as a MedVA can be isolating, as you may have limited interaction with
colleagues. Loneliness and lack of social interaction can be a downside for some individuals.

Self-Discipline: Virtual work requires strong self-discipline and time management skills.
Procrastination can be a significant challenge when working from home.

Unpredictable Workload: The workload for MedVAs can be variable, with busy periods and lulls.
This inconsistency may affect your income and job stability.

Technical Challenges: Managing electronic health records (EHRs) and using healthcare-specific
software can be complex and may require continuous learning to stay up to date.

Security and Privacy Concerns: Handling sensitive patient information comes with significant
responsibilities. MedVAs must adhere to strict privacy and security regulations (e.g., HIPAA) and be
vigilant to protect patient data.

Client Dependence: As a virtual assistant, your income may rely on a few key clients or contracts.
Losing a major client can be financially challenging.

Continual Learning: The healthcare industry is constantly evolving. MedVAs must stay updated with
industry trends, software changes, and regulations, which may require ongoing education and
training.

Competitive Market: The virtual assistant field, including MedVAs, is competitive. Building a client
base and finding well-paying opportunities can be challenging, especially for newcomers.

Common Medical Terminologies

The building block for most medical terms is the word root, or the primary body of a word. At times, a
medical term can be made up of compound words. A compound word may consist of two word roots,
such as in the case of collarbone (collar + bone).

To facilitate the pronunciation of words, a combining vowel is placed in between word roots. A
significant number of medical terms use the vowel “o”. However, it’s good to note that “o” isn’t the
only vowel.
The following table demonstrates examples of roots and combining forms.

Combining
Word Combining Form Meaning Use in a Word
Root Vowel
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acr + o acr/o extremity acrocyanosis

psych + o psych/o mind psychology
chol + e chol/e bile cholesterase

Prefixes and Suffixes

Prefixes and suffixes may accompany a word root to alter its meaning. A prefix is attached before the
word, while a suffix is placed at the end of a word root. Sometimes, a word may consist of a prefix
and a suffix only.

Writing Medical termsBuilding words follows certain guidelines. Table 2 presents some common
rules in word building.

Guidelines Examples
Linking In most instances, the com- leuk/o + cyte leukocyte
combining bining vowel is retained amid
forms combining forms. cardi/o + logy cardiology
Linking combining Use a combining vowel if the crani/o + tomy craniotomy
forms and suffixes suffix begins with a
consonant. derm/a + tology dermatology
Linking Omit the combining vowel if appendic/o + itis appendicitis
combining the suffix begins with a
forms and vowel. enter/o + ic enteric
suffixes with
initial vowels
Linking other word Usually, prefixes need not be dys + pepsia dyspepsia
parts and prefixes changed when linked with other
word parts. intra +dermal intradermal

To better recognize the parts that make up a medical term, word division is commonly used
throughout this course. For instance, appendectomy may be written as append + ectomy to highlight
its component parts.

Abbreviations and Pharmacology

An abbreviation is a shortened form of a word or phrase. Abbreviations can be in the form of:
Q
Letters: The abbreviation for chest x-ray is CXR.
Q
Shortened words: The abbreviation “tab” is short for “tablet.”
Q
Acronyms: The acronym CPR stands for cardiopulmonary resuscitation.

Note: Abbreviations and symbols should be used cautiously, especially when med- ications are
involved. The Institute for Safe Medication Practices (ISMP) and The Joint Commission (TJC)
provide a list of unsafe abbreviations and symbols.
The branch of science that deals with the preparation, properties, uses, and actions of drugs is
known as pharmacology. Drugs, most commonly referred to as medicines, are used in the
prevention and treatment of diseases. Concepts related to drugs include the following:
Q
Route of administration: ways in which drugs can be given (usually via the mouth or via an
injection)
Q
Generic name: nonproprietary name of the drug (for example, ibuprofen)
Q
Trade name: company name, otherwise known as the brand name (for example, Motrin)
Plurals
The plural form of many medical terms follows the rules used in common language.
 VA’s of the Future 11

Word endings Singular form Plural Form

Consonants other than s, h, or contusion contusions
y
s, ch, sh virus viruses
y allergy allergies

General Guidelines in Forming Plurals of Nouns with Special Endings

Singlar Plural Ending Examples (Singular) Examples (Plural)
Ending
is es diagnosis, anastomosis Diagnoses and anasromoses

*Some words ending in is take on their plural form by omitting the is and adding ides, as in
arthritis and arthritides
um a atrium, ostium atria, ostia
us i bronchus, alveolus bronchi, alveoli
*Some words ending in us take on their plural form by omitting the us and adding era or ora, as in
viscus to viscera and corpus to corpora.
a ae cava, vertebra cavae, vertebrae
ix ices appendix, cervix appendices, cervices
ex ices apex apices
ax aces thorax thoraces
ma s or condyloma condylomas or condylomata
mata
on a spermatozoon spermatozoa
*Some words ending in on take on their plural form by adding s, as in chorion to chorions
nx nges phalanx phalanges

Medical Specialist and their specialites.

Identifying medical specialists and their specialties is made easy by recognizing the meanings
of the suffixes attached to the word root. For example, the suffix -logy refers to the “study or
science of.” Anesthesiology is the branch of medical science that specifically
deals with the study of anesthesia or anesthetics. On the other hand, the suffix -logist means “one
who studies” or “specialist.” An anesthesiologist is a physician who special- izes in anesthesia. It’s
important not to confuse anesthesiologist with anesthetist. The suffix -ist means “one who”; hence,
an anesthetist is one who administers anesthesia. An anesthetist can be a physician or a nurse,
while an anesthesiologist is a medical doctor or physician. Study the following suffixes and their
meanings.

SUFFIXES: MEDICAL SPECIALISTS AND THEIR SPECIALTIES

Medical Specialists Medical Specialties
Suffix Meaning Example Suffix Meaning Example
-er, one who internist -ac, -al, -ic, pertaining to obstetrical
-ist ical
-iatrici practitioner pediatricia -logic, -logical pertaining to the psychological
an n study of
-logist one who pulmonolo -iatrics, -iatry medical profes- pediatrics
stud- gist sion or
 VA’s of the Future 12

ies, treatment
special
ist
-logy study or science gynecology
of

The following table lists some of the most common combining forms associated with medical
specialties and specialists.

Combining Meaning Medical Specialty Medical Specialist

Form
cardi/o heart cardiology cardiologist
dermat/o skin dermatology dermatologist
esthesi/o feeling or sensation anesthesiology anesthesiologist
gynec/o female gynecology gynecologist
immune/o immune immunology immunologist
ne/o, nat/o new, birth neonatology neonatologist
ophthalm/o eye ophthalmology ophthalmologist
path/o disease pathology pathologist
radi/o radiation or radius radiology radiologist
ur/o urinary tract or urine urology urologist

Surgical Procedures.

A significant number of medical terms refer to surgical procedures. Generally, the suf- fixes used will
give you an idea about the type of surgery or procedure performed. For instance, the suffix -ectomy
means surgical removal. Polypectomy and adrenalectomy refer to the excision or removal of polyps
and adrenal glands, respectively. Knowing a familiar word related to the suffix makes it easier to
analyze a medical term. This process is known as word association. Take a look at the following
table.

SUFFIXES: SURGICAL PROCEDURES

Suffix Meaning Word Association
-centesis surgical puncture to aspirate or Paracentesis is a puncture of the perito-
remove fluid neal cavity to remove fluid for
diagnostic or therapeutic purposes.
-ectomy excision (surgical removal or Excision of the appendix is referred to
cutting out) as an appendectomy.
-lysis process of loosening, freeing, or This suffix can also mean dissolving or
destroying destruction, as in hydrolysis.
-pexy surgical fixation (securing in a Nephropexy is a surgical fixation of a
fixed position) kidney that descends when the
patient stands up.
-plasty surgical repair Rhinoplasty is a plastic surgery of the
nose and is done for several
reasons.
-rrhaphy suture (fusing a wound by Herniorraphy is surgical repair of the
stitches) hernia with suture of the abdominal
 VA’s of the Future 13

wall.
-scopy visual examination with the use of a Colonoscopy is a means of visualizing
lighted instrument the colon with the use of a fiber-optic
instrument.
-stomy creation of an opening Colostomy is a surgical procedure that
creates an opening for the colon or
large intestine through the abdomen.
-tome an instrument used for cutting A microtome is used to cut thin sections
of tissue.
-tomy incision (cutting into tissue) Sternotomy is an incision of the sternum
usually performed during heart surgery.
-tripsy surgical crushing, breaking, or Lithotripsy is the surgical crushing of a
pulverizing renal calculus or stone.

Body Structures
Some of the combining forms for body structures have already been introduced when naming
medical specialists. In this section, you’ll be presented with additional combining forms and the most
frequent word associations used. Hepat/o is one of the most common combining forms used in the
medical field. Note that hepat/o means liver; hence, hepa- titis refers to an inflammatory condition of
the liver. More examples are presented in the following table.

COMBINING FORMS FOR A NUMBER OF BODY STRUCTURES

Combining Form Meaning Word Association
aden/o gland Adenopathy refers to the enlargement
of the glands.
angi/o vessel Angioplasty is a procedure used to
rees- tablish blood flow through
partially or fully blocked blood
vessels.
bi/o life or living Biopsy is a procedure used to
extract cells or tissues for
examination.
blephar/o eyelid Blepharitis is an infection of the eyelids.
cerebr/o, brain Cerebrospinal fluid is a clear,
encephal/o colorless fluid found in the brain
and the spinal cord.

Encephalopathy is a general term

that refers to a disorder or
disease of the brain.
col/o colon or large intestine Colitis is an inflammation of the colon’s
inner lining.
faci/o face Facial relates to the face.
hepat/o liver Hepatomegaly is enlargement of
the liver.
mamm/o, mast/o breast Mammogram is an x-ray of the breast.

Mastitis is an infection of the

breast tissue.
muscul/o, my/o muscle The musculoskeletal system is an
organ system responsible for
movement and activity.

Myosin is one of the muscle proteins.

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myel/o bone marrow or spinal cord Myelogram is a means of examining

the spinal canal using a
combination of dye and x-ray.
oste/o bone Osteoporosis is a disease that
weakens the bones, thereby
increasing the risk for fractures.
pulm/o, pulmon/o, lungs Pulmonary refers to the lungs.
pneum/o,
pneumon/o Pneumatic refers to gas or air.

Pneumothorax is the accumulation of

air or gas in the chest.
tonsil/o tonsil Tonsillectomy is the surgical removal
of the tonsils.
trache/o trachea (windpipe) Tracheitis is an inflammation of the
trachea.
vas/o vessel Widening of the blood vessels is
known as vasodilation.

Symptoms or Diagnosis
Symptom and diagnosis are common terms used in the medical field. A symptom indi- cates a
disorder or disease in which changes in health status are perceived by the client. For instance, a
client says: “My stomach hurts.” Diagnosis, on the other hand, is the scientific determination of a
disease process or condition after evaluation. “Peptic ulcer disease” is an example of a medical
diagnosis.

SUFFIXES: SYMPTOMS OR DIAGNOSIS

Suffix Meaning Word Association
-algia, -dynia pain Arthralgia is joint pain. Vulvodynia is a chronic pain
condition affecting a wom- an’s external genitalia.

-cele hernia (results when Omphalocele is an abdominal wall defect in which the
organ pushes abdominal organs protrude through an opening at
through the organ or the base of the umbilical cord.
muscle that contains
it)
-ectasia, dilatation Telangiectasia is the dilation of the super-
-ectasis ficial blood vessels.

Lymphangiectasis is the dilation of the lymphatic

vessels.
-edema swelling Edema denotes the presence of excess
fluid in the tissues, causing swelling.

Angioedema involves the precipitous swelling of

the tissues under the skin, usually due to an
allergic reaction.
-emesis vomiting Emesis denotes vomiting.

Hyperemesis means excessive vomiting.

-emia condition of the blood Anemia refers to a decrease in red blood cells or
hemoglobin in the blood.
 VA’s of the Future 15

-ia, -iasis condition Hysteria is a mental disorder attributed to women in

the nineteenth century.

Filariasis is a parasitic disease caused by microscopic

worms.
-itis inflammation Inflammation of the voice box or larynx is
known as laryngitis.
-ith stone or calculus Fecalith is a hard mass consisting of feces.

-malacia soft, softening Chondromalacia patella is the softening of the

cartilage underneath the knee.
-mania excessive preoccupation Pyromania is a compulsion to set things
on fire.
-megaly enlargement Cardiomegaly is the enlargement of the heart.

SUFFIXES: SYMPTOMS OR DIAGNOSIS (continued)

Suffix Meaning Word Association
-oid resembling Mucoid means similar to mucus.
-oma tumor Lymphoma refers to a group of blood cancers originating
from the lymphatic system.

-osis condition (usually an Psychosis is a group of disorders affect- ing the mind.
abnor- mal
condition,
occasionally
refers to an
increase)
-pathy disease Cardiomyopathy is a group of diseases affecting the
cardiac muscle.
-penia deficiency Neutropenia refers to abnormally low lev- els of
neutrophils, a type of white blood cell.

-phobia abnormal fear Phobia refers to extremely strong fear or dislike of

something. Fear of being in an enclosed space or area
is known as claustrophobia.

-ptosis prolapse (sagging) Drooping eyelids is ptosis.

-rrhage, excessive bleeding Hemorrhage means bleeding, which can be external or
-rrhagia internal.
-rrhea flow or discharge Amenorrhea is the absence of menstrual
flow.
-rrhexis rupture Rupture of the bowels is referred to as
enterorrhexis.
-spasm cramp, twitching Vasospasm is the spasm of the blood vessels.

-stasis stopping, controlling Hemostasis is the normal bodily response to stop

bleeding or hemorrhaging.
 VA’s of the Future 16

Miscellaneous Suffixes

These word parts aren’t categorized under a specific group, but note that they’re fre- quently used in
medical terminologies. The word microscope (word part= micro), for example, is used not only by
healthcare professionals but in customary language as well.

MISCELLANEOUS SUFFIXES
Suffix Meaning Examples
-able, -ible capable of, able to injectable, edible
-ac, -al, -an, -ar, -ary, pertaining to iliac, dermal, median, ulnar, capil- lary, meningeal,
-eal, -ic, -ive, -tic hepatic, invasive, cyanotic

-ase enzyme lipase, amylase

-eum, -ium membrane peritoneum, myocardium
-ia, -ism condition or theory paranoia, dwarfism
-iac one who suffers hemophiliac
-opia vision hyperopia
-ose sugar fructose
-ous pertaining to or cancerous
character- ized
by
-y state or condition atrophy

MISCELLANEOUS WORD PARTS

Word Part Meaning Word Association
adip/o, lip/o fat adipose, hyperlipidemia
amyl/o starch amylase
glyc/o sugar hyperglycemia
hemat/o blood hematology
lact/o milk lactation
litho/o stone lithotripsy
micro- small microscopy
muc/o mucus mucous
prote/o, protein/o protein proteolysis, proteinuria
pyr/o fire pyromania

Medical terms for patient status

Acute: Patient with a sudden flare-up or potentially severe issue who needs immediate care.
Critical: Patient’s vital signs are out of the normal range and patient may be unconscious.
Inpatient: Status of a patient who requires hospital admission.
Observation: A temporary status that allows patients to continue receiving care for a set amount of
time in the hospital while the physician determines whether admission or discharge is best.
Outpatient: Status of a patient who is not admitted to a hospital for overnight care. This can include
clinic visits, same-day surgeries, and one-day emergency room visits.

Abbreviations and acronyms

AC: Ante cibum, or "before meals," indicating when a patient should take medication
 VA’s of the Future 17

ADR: Adverse drug reaction

ALOC: Acute loss of consciousness
BMI: Body mass index, a measurement of body fat based on height and weight
BP: Blood pressure, a measurement of the pressure exerted by the flow of blood upon vessel walls.
This measurement is expressed using two numbers, the systolic, or highest pressure and the
diastolic, or lowest pressure.
CHF: Congestive heart failure
DNR: Do not resuscitate, an indication that the patient does not want CPR or other life-saving
procedures performed on them
ECG or EKG: Electrocardiogram, a device that records heartbeats
EMS: Emergency medical services
FX: Fracture
HR: Heart rate, the number of times a person's heart beats, usually measured per minute
LFT: Liver function test
MRI: Magnetic resonance imaging, diagnostic imaging that uses magnetism and radio waves to
produce images of internal organs
PT: Physical therapy
Rx: Prescription
UTI: Urinary tract infection

Diseases and conditions

Acute: A condition that is often severe but starts and ends quickly
Angina: Intermittent chest pain normally caused by insufficient blood flow to the heart
Benign: Refers to a tumor that is neither cancerous nor malignant
Chronic: Describes a condition that is persistent or recurring
Edema: Swelling as a result of fluid retention or buildup
Embolism: A clot caused by blood, fat, air or other types of fluid, gas or foreign material
Fracture: A cracked or broken bone
Hypertension: Unusually high blood pressure
Hypotension: Unusually low blood pressure
Intravenous: Administration of medication or fluids by vein
Lesion: Damage or change to tissue, such as a cut, a wound or a sore
Malignant: Refers to the presence of cancerous cells in a tumor or growth
Myocardial infarction: Also known as a heart attack, where the heart is deprived of blood due to
arterial blockage
Remission: Describes a disease that is not getting worse
Sepsis: An imbalance in the body's response to infection that injures the body's tissues and organs
Thrombosis: A blood clot that forms inside a blood vessel restricting blood flow

Prefixes and Suffixes

You can often determine what a medical term means if you understand some basic prefixes and
suffixes, such as:
A- or an-: Lacking or without
Ab-: Away from
-algia: Indicates pain or a painful condition
Cardio-: Related to the heart
Ecto- or exo-: Outside of
-ectomy: Removal through surgery
Hyper-: Above, beyond or in excess
-itis: An inflammation
-mortem: Relating to death
-plasty: Repair through surgery
Post-: After or behind
-rrhea: A discharge or a flow
-somnia: Related to sleep
Trans-: Across or through
-trophic: Relating to nutrition
Vas(o)-: Relating to a vessel
Aqua-: Pertaining to water
Asphyxia: Choking or loss of consciousness due to oxygen deprivation
 VA’s of the Future 18

Carcin(o)-: Related to or causing cancer

Cyto-: Pertaining to a cell or cells
Derma-: To do with the skin
Digit: Either a finger or a toe
Encephal(o)-: To do with the brain
Gastr(o)-: Related to the stomach
Lact-: Pertaining to milk
Men-: A month or occurring monthly
Nephr(o)-: Related to the kidneys
Onc(o)-: To do with tumors or masses, often related to cancer
Ov-: Pertaining to eggs
Pulmon(o)-: To do with the lungs
Stasis: Causing the flow of a fluid, such as blood, to slow or stop
Viscous or viscosity: Sticky or thick, thickness

Procedures and tests

Here are some common medical procedures and tests:

Appendectomy: Surgical procedure to remove the appendix

Biopsy: Removal of a small tissue sample for testing
Blood culture: Test to reveal the existence of fungi or bacteria in the blood, possibly indicating an
infection
Blood swab: Taking a blood sample using a cotton-tipped stick
Coronary bypass: Surgical transplant of a healthy blood vessel into the heart to bypass or replace an
unhealthy vessel
Dialysis: Process to filter the blood, usually performed as a result of kidney failure
Fusion: Joining together adjacent bones or vertebrae to increase stability
Glucose test: A test to discover the quantity of a particular type of sugar in the bloodstream
Hysterectomy: Surgical procedure to remove the uterus
Intubation: Medical insertion of a tube into the body, for example, into the throat to assist with
breathing
Lead test: A test to reveal the quantity of lead in the bloodstream
Lumbar puncture or spinal tap: Drawing of cerebrospinal fluid from the lumbar region of the back
using a hollow needle
Mastectomy: Surgical procedure to remove part or all of the breast
Occult blood screen: Use of a chemically treated card or pad to test for blood hidden in a stool sample
Ultrasound: Imaging produced by high-frequency sound waves, usually used to view internal organs
X-ray: Use of high-energy electromagnetic radiation to create images of internal bones and organs

Tools and equipment

Here are some common medical tools, devices and appliances:
Blood lancet: A double-edged blade or needle used to obtain blood samples
Defibrillator: A device that discharges an electric current to the heart to correct cardiac arrhythmia or
arrest
Dialyser: A machine that replaces the function of the kidneys by removing solutes, excess water and
toxins from the blood
Endoscope: An optical instrument containing a tube with a lighted end used for internal examinations
Forceps: A hinged instrument, like scissors, used to grasp and hold objects
Hypodermic needle: A very thin, hollow needle used with a syringe to inject substances into the body
or to extract blood
Nebulizer: A device used to deliver medication in an aerosol form through inhalation
Ophthalmoscope: An instrument used to examine the eye's fundus, retina and other structures
Otoscope or auriscope: A device for examining the external ear cavity
Pulse oximeter: A small device that clips to the finger, toe or earlobe used to measure blood oxygen
saturation
Reflex hammer: A specially designed hammer used to test deep tendon or motor reflexes
Speculum: An instrument used when examining body orifices to help widen the opening
Spirometer: A device that measures the amount of air breathed in and out by the lungs
 VA’s of the Future 19

Splint: A tool for immobilizing and protecting displaced or injured body parts such as broken bones or
dislocated joints
Stethoscope: A device for listening to the heartbeat or breathing
Ventilator: A machine that provides mechanical assistance with breathing

Charting Medical Terminologies

The charts providers use for making notes are often filled with this kind of medical terminology. You
might even know some of them by a different name.

1. Abrasion: A cut or scrape that typically isn’t serious.

2. Abscess: A tender, fluid-filled pocket that forms in tissue, usually due to infection.
3. Acute: Signifies a condition that begins abruptly and is sometimes severe, but the duration is short.
4. Benign: Not cancerous.
5. Biopsy: A small sample of tissue that’s taken for testing.
6. Chronic: Signifies a recurring, persistent condition like heart disease.
7. Contusion: A bruise.
8. Defibrillator: A medical device that uses electric shocks to restore normal heartbeat.
9. Edema: Swelling caused by fluid accumulation.
10. Embolism: An arterial blockage, often caused by a blood clot.
11. Epidermis: The outer layer of the skin.
12. Fracture: Broken bone or cartilage.
13. Gland: An organ or tissue that produces and secretes fluids that serve a specific function.
14. Hypertension: High blood pressure.
15. Inpatient: A patient who requires hospitalization.
16. Intravenous: Indicates medication or fluid that’s delivered by vein.
17. Malignant: Indicates the presence of cancerous cells.
18. Outpatient: A patient who receives care without being admitted to a hospital.
19. Prognosis: The predicted outcome of disease progression and treatment.
20. Relapse: Return of disease or symptoms after a patient has recovered.
21. Sutures: Stitches, which are used to join tissues together as they heal.
22. Transplant: The removal of an organ or tissue from one body that is implanted into another.
23. Vaccine: A substance that stimulates antibody production to provide immunity against disease.
24. Zoonotic disease: A disease that is transmissible from animals to humans.

Top 15 Practices and Specialties you may encounter as a Medical VA

1. General Practice/ Family Medicine: General practice is similar to urgent care or a general
health clinic. General practitioners offer general medical services to patients of all ages but do
not typically specialize in a particular area. Besides treating your medical condition, your GP
also identifies the areas that need continued care from a specialist
2. Dental: Dental Clinics that provide dental services and oral prophylaxis.
3. Podiatry: Also known as Chiropody. Practice that focuses on the study, diagnoses, and
treatment of disorders of the foot and ankle.
4. Radiology: Radiologists are medical doctors that specialize in diagnosing and treating
injuries and diseases using medical imaging (radiology) procedures (exams/tests) such as
X-rays, computed tomography (CT), magnetic resonance imaging (MRI), nuclear medicine,
positron emission tomography (PET) and ultrasound.
5. Psychiatry:Psychiatrists assess all of your mental and physical symptoms. They make a
diagnosis and work with you to develop a management plan for your treatment and recovery.
Psychiatrists provide psychological treatment, prescribe medications and do procedures such
as rTMS or electroconvulsive therapy.
6. Internal Medicine: The specialty of internal medicine covers a wide range of conditions
affecting the internal organs of the body - the heart, the lungs, the liver and gastro-intestinal
tract, the kidneys and urinary tract, the brain, spinal column, nerves, muscles and joints.
Although some diseases specifically affect individual organs, the majority of common
diseases - arteriosclerosis, diabetes, high blood pressure and cancer may affect many
internal organs of the body.
7. Neurology: Practice that focuses on the brain and spinal cord.
8. Dermatology: Practice that focuses on the skin and different skin condition
9. Pediatrics: Deals with very young patients or children
10. Cardiology: Practice that focuses on the heart
 VA’s of the Future 20

11. Allergy & Immunology: Allergy and immunology is the area of medicine dedicated to the
care and treatment of health concerns and conditions of the immune system, including
allergic disease and related symptoms and reactions — from asthma, rhinitis, sinus problems,
or seasonal allergies to life-threatening reactions to drugs, food, vaccines, and more.
12. Endocrinology:Practice that focuses on hormones
13. Urology: Urology is a part of health care that deals with diseases of the male and female
urinary tract (kidneys, ureters, bladder and urethra). It also deals with the male organs that
are able to make babies (penis, testes, scrotum, prostate, etc.)
14. Pediatric Pulmonology: A doctor who specializes in breathing and lung problems in
children. They can help your child and your family learn to manage the symptoms of breathing
problems, prevent complications, and improve their quality of life
15. Occupational Medicine: Occupational medicine (also known as “occupational health”) is
focused on the treatment of work-related injuries and illnesses.

Establishing Professional Relationships with Patients, Healthcare Professionals and Doctors

In order to create professional relationships, it starts with developing people's connections.

Connections are something people crave because they create a sense of belonging. Much is written
about developing employee engagement based on positive employee relations, but there is another
type of relationship of equal importance – the professional relationship. This type of relationship
focuses on developing a network of colleagues and industry connections that support as needed,
foster career-building, make work more productive and promote inclusiveness. Professional
relationships are built on trust, require certain skills and a high level of self-awareness and produce
mutual value or social reciprocity.

Benefits of Developing and Maintaining Professional Relationships

When you create professional relationships, several benefits are realized. The basic characteristics of
strong professional relationships are respect, trust, inclusion, self-awareness, and open and honest
communication. On the foundation of these characteristics flow the benefits, some of which are the
following.

● Increased job satisfaction through relationships with colleagues

● Increased potential for identification of career opportunities
● Enhanced possibility for career advancement
● Improved leadership and workforce productivity through greater access to know-how,
expertise, information, new perspectives, etc.
● Ability to source talent through contacts
● Creation of a support network
● Creation of a more connected workplace
● Improved lines of communication throughout the organization
● Increased positivity in the leader experience
● More effective as a manager or supervisor
● Better prepared to develop positive employee-employer relationships and improve the
employee experience for the leader's team members
● Gains influence in the organization
● Leaders become role models for their staff members
● Creating Relationships = Networking
● Creating professional relationships is networking. The relationships are internal and external
and focus on the future and the operational present. When done right, the process is strategic
because the planned connections help leaders identify future challenges, priorities, and
opportunities as much as it delivers the other mentioned benefits.

How to Create Professional Relationships

Developing professional relationships today is more complex because many people work remotely.
But it's important to include inhouse and remote connections when building professional relationships.
Following are some of the ways to build a professional network.
Identify the Professional Relationships to Create
Creating professional relationships is a strategic effort in that you are identifying colleagues who will
deliver the greatest value. It is not a random process. You can use relationship mapping to identify the
strategic professional relationships that deliver the most value. The principle of social reciprocity is a
 VA’s of the Future 21

psychological term for a mutually beneficial exchange. In a successful and productive professional
relationship, both sides benefit. You want to identify the professionals who will boost your career
through interactions, provide new perspectives concerning operations or initiatives, or deliver some
other value like improved decision-making. Identifying your needs is the first step.
Practice Open Communication
Communication is crucial in any relationship. Open communication is key to strong relationships
because it gives people a chance to share opinions, present ideas, and even express complaints
without fear of repercussions. You have to be willing to share information, ask, and give feedback with
an open mind to create professional relationships with value. This is one element of trust-building, and
you contribute to a culture of transparency, positive relations, and innovation while building
professional relationships.
Use Many Communication Channels
Using a variety of communication channels. Meet face-to-face whenever possible because there is no
equal substitute for purposes of relationship building. You want to spend time with others by visiting
colleagues when possible. After face-to-face communication, the next best form is the video call. After
that, there are phone calls and various digital communication tools, including email, chat, text, and
direct messaging. Create communication opportunities like open Zoom rooms where people can
connect anytime. With so many people working remotely, developing the skills needed to effectively
use digital communication is important.
Practice Diversity of Thought
An important skill to apply when you create professional relationships is assessing your biases and
perspectives. Keeping an open mind is important because honest conversations end when one
person is judgmental. The mind is closed to new perspectives and opinions, and a trusting
relationship is impossible to develop. Creating professional relationships can play an important role in
promoting the inclusion of diverse perspectives, which in turn promotes innovation. When determining
who to connect with, form high-value relationships with diverse colleagues.
Take the Lead in Creating Professional Relationships
It takes a certain amount of assertiveness to develop new relationships. Someone must be willing to
reach out first, so take advantage of every opportunity to engage with colleagues. There are a variety
of approaches.
Ask for an introductory meeting.
Offer something of value to the person, whether it is assistance on a project, resources you have
cultivated over time, etc. Ask a colleague for their perspective, opinion, or input on a project or
problem you are experiencing. Share information, like a report you prepared or research conducted.
Ask to attend meetings that are not directly related to your department.
It should also be added that you need to consider the whole person. Each person has a personal
identity and a work identity. Expressing an interest in the whole person and sharing yourself
holistically also can deepen professional relationships. Though you are developing relationships with
people who are mostly leaders already, work isn't the only thing of importance in their lives. A
common suggestion is to begin a new relationship by asking about things like charity work, family, and
interests. This sends a message that you are not self-serving and have a sincere interest in the
person.
Be an Active Listener
Many times, people think they are listening. In reality, they think about their plans, ideas, perspectives,
opinions, or goals. They aren't listening to what the other person is saying. Possible responses in any
exchange include reflecting, asking for more information, deflecting in which a discussion is shifted to
another topic, and advising. The first two responses – reflecting and asking for more information - are
helpful, while the last two – deflecting and advising based on personal biases - are not. Active
listening means approaching the conversation with the right attitude and hearing what the person is
saying, not what you think they should be saying. You reflect on the information with an open mind,
ask for more information, and pivot when it makes sense. Active listening also means keeping body
language positive and encouraging sharing. This is one of the best ways to cultivate a positive
professional relationship.
Follow Through on Commitments
After you create professional relationships, they need nurturing. Being friendly and interested in
another person and their work is not enough. You build trust through consistent effort, following
through on commitments, and being truthful. Truthfulness includes admitting weaknesses as much as
touting strengths. When trust exists, your opinions have more value, and colleagues will seek you out
 VA’s of the Future 22

as much as you seek them. Following through on commitments also makes it clear that you value the
relationship.
Learn the Other Person's Communication and Work Style
Solidifying the professional relationship is only possible when you understand the other person's
communication and work style. How does the person like communicating – face-to-face, via email,
video call, etc. Work styles can vary considerably. For example, some people are organized and
structured, while others are dynamic and fast-paced. The relationship is likely to falter if you try to
push a thoughtful, methodical person with a rapid dynamic work approach.
Keep in Contact
Hold regular conversations and make regular contact with your colleagues. Though this is obvious, it's
easy to get sidetracked due to workloads and the frequent leadership challenges to address.
However, remember that well-chosen professional relationships can provide new perspectives and
ideas that may help streamline work or overcome those challenges. Keeping in contact not only
nurtures the professional relationship. It keeps the exchange of ideas and information flowing.

Why Have Good Work Relationships?

Human beings are naturally social creatures. The more comfortable co-workers are around one
another, the more confident they'll feel voicing opinions, brainstorming, and going along with new
ideas, for example. This level of teamwork is essential to embrace change, create, and innovate. And
when people see the successes of working together in this way, group morale and productivity soars.

Good work relationships also give you freedom. Instead of spending time and energy dealing with
negative relationships, you can, instead, focus on opportunities – from winning new business to
focusing on personal development. And having a strong professional circle will also help you to
develop your career, opening up opportunities that otherwise might pass you by.

Defining a Good Relationship

A good work relationship requires trust, respect, self-awareness, inclusion, and open communication.
Let's explore each of these characteristics.

● Trust: when you trust your team members, you can be open and honest in your thoughts and
actions. And you don't have to waste time or energy "watching your back."
● Respect: teams working together with mutual respect value one another's input, and find
solutions based on collective insight, wisdom, and creativity.
● Self-awareness: this means taking responsibility for your words and actions, and not letting
your own negative emotions impact the people around you.
● Inclusion: don't just accept diverse people and opinions, but welcome them! For instance,
when your colleagues offer different opinions from yours, factor their insights and perspective
– or "cultural add" – into your decision-making.
● Open communication: all good relationships depend on open, honest communication.
Whether you're sending emails or direct messages, or meeting face-to-face or on video calls,
the more effectively you communicate with those around you, the better you'll connect.

How to Build Good Work Relationships

Building close connections with people can take time and effort. But there are also some simple things
you can do to forge better relationships with your colleagues.

1. Identify Your Relationship Needs. Do you know what you need from others? And do you know
what they need from you? Understanding these needs can be instrumental in building better
relationships.
2. Develop Your People Skills. Good relationships start with good people skills. Take our quiz:
How Good Are Your People Skills? to test how well you collaborate, communicate, and deal
with conflict. The quiz will also point you toward useful tools to improve any weak areas.
3. Focus on Your EI. Emotional intelligence (EI) is your ability to recognize your own emotions,
and better understand what they're telling you. By developing your EI, you'll become more
adept at identifying and handling the emotions and needs of others.
4. Practice Mindful Listening. People respond better to those who truly listen to what they have
to say. By practicing mindful listening, you'll talk less and understand more. And you'll quickly
become known as trustworthy.
 VA’s of the Future 23

5. Schedule Time to Build Relationships. If possible, you could ask a colleague out for a quick
cup of coffee. Or give a "one-minute kindness" by commenting on a co-worker's LinkedIn post
you enjoyed reading or sending them a quick message to check in with how they're doing.
These little interactions take time but lay the groundwork for strong relationships.
6. Manage Your Boundaries. Make time, but not too much! Sometimes, a work relationship can
impair productivity, especially when a friend or colleague begins to monopolize your time. It's
important to set your boundaries and manage how much time you devote to social
interactions at work.
7. Appreciate Others. Everyone, from your boss to the intern, wants to feel that their work is
appreciated. So, genuinely compliment the people around you when they do something well.
Praise and recognition will open the door to great work relationships.
8. Be Positive. Focus on being positive. Positivity is contagious and people gravitate to those
that make them feel good.
9. Avoid Gossiping. Office politics and gossip can ruin workplace relationships. If you're
experiencing conflict with someone in your group, talk to them directly about the problem.
Gossiping with other colleagues will only exacerbate the situation, accelerating mistrust and
animosity.

Handling Difficult Work Relationships

Sometimes, you'll have to work with someone you don't get on with. With the rise of virtual
workspaces, many colleagues are benefiting from some time apart. But even communicating virtually
can cause misunderstandings or tension.
While it's natural to avoid people who cause friction, it's not always feasible and can damage team
cohesion. So, here are a few tactics to mend or maintain a professional relationship.

1. Reflect on your positive history. If a good relationship has taken a turn for the worse after an
incident, research shows that reflecting on positive experiences with a co-worker can
strengthen a broken bond. Another option is to use an impartial mediator to bridge the divide
and find a quick resolution.
2. Look at yourself. When we feel negative about someone, we can become impatient, get
angry, and demotivate others. And others can direct those negative behaviors back at us. The
Betari Box can help to break this cycle of conflict, stopping these harmful attitudes and
behaviors in their tracks.
3. Find mutually-beneficial goals. Have you considered that a difficult relationship might be due
to a power imbalance? You can use professor John Eldred's power strategies model to
identify any conflicting goals or power imbalances, and devise a method to communicate
better and improve your relationship.

Phone Etiquette
Phone etiquette is essential to maintaining customer satisfaction and representing your brand
professionally. Customer service over the phone matters greatly in customer satisfaction and your
brand’s professionalism.

What is phone etiquette, and why is it important?

Proper phone etiquette is your use of greetings, word choice, tone of voice, active listening, greetings
and general manners on the phone. A potential client’s first impression of you is often over the phone,
and how you communicate with them might decide whether you gain or lose them as a customer.

The benefits of maintaining great phone etiquette as you provide customer service include the
following:

Making great, long-lasting first impressions: Callers judge your business by how you interact
with them, handle their requests, or answer their questions. Good communication is key to
establishing and maintaining a positive relationship with your customers.
Compensating for the lack of nonverbal cues: It can be difficult to communicate with
customers over the phone, since neither party can pick up on body language and other
nonverbal cues. Setting phone etiquette standards and training your team to adhere to them
can make up for this gap.
Developing a great reputation: The top-notch customer service to which excellent phone
etiquette often leads can build your business a great reputation. That’s because 72% of your
 VA’s of the Future 24

customers tell at least six people about their best customer service experiences – and that
could include your business. Over time, this could lead to your company forming a reputation
for great customer service.
Retaining customers: Bad phone etiquette leads to poor customer service, and bad customer
service leads to customer churn. And you really don’t want a rotating cast of customers: It’s
five to 25 times more expensive to acquire customers than retain them, according to Harvard
Business Review.
Identifying new customer needs: A customer service team with great phone etiquette can
expand beyond solving immediate problems and identify other customer needs. A
conversation about a tech issue could turn into a customer saying, “I wish your company
offered this product or service too.” And then you can implement it, but you might never have
identified it if your team lacked phone etiquette.
Whenever you’re on the phone with customers, it’s important to use your words, tone and
professionalism to convey what you are trying to get across. Continuously practice the right
etiquette and ensure your staff is also adhering to it. Consistency is key.

10 phone etiquette tips for businesses

To start, here are 10 phone etiquette tips for call center customer service for small businesses.

1. Be consistent.
Have everyone answer the business line consistently. If it’s an inbound call, all the customer wants to
know is that they got the right number. Your “hello” should be brief. Train staff to use a professional
greeting that mentions the company and then their own names. “How can I help you?” is assumed, so
don’t waste precious time adding those five words. “Hello. Mary’s Mittens. This is Becky” is sufficient.

2. Never interrupt.
Don’t interrupt a complaining customer. It can be hard not to do this, but train your team to listen to the
whole problem, no matter how long it takes. Even if call center employees will eventually hand off the
call to another member of your staff, listening to the whole story is important so the customer feels
taken care of.

3. Get to know the hold button.

Does everyone at your company know how to use your business phone system? The hold button is
your friend. Never put the phone to your chest to muffle the mouthpiece so you can speak among
yourselves. Clients may hear things you don’t want them to hear.

4. Get to know the transfer button.

You need to know how to transfer someone to another team member. Say to the client, “The best
person to handle this is Jane, so I’m going to transfer you.” If it’s going to take time for you to locate
Jane or explain the problem to her, tell the client it’ll be a while. For instance, say, “It will take me
about three or four minutes to get Jane up to speed, so can I please put you on hold?” Most people
will say yes. Then Jane must answer the phone with some knowledge of the problem, not starting
from square one.

5. Keep customers informed.

It’s important to train your team on this. They have to give the client a list of what they’re going to do,
then a longer time frame than necessary. Why? Because when you fix the problem in less time than
you stated, they know you went to bat for them. You’ll have a loyal customer at that point. Take longer
than you said, and they’ll be steaming mad.

6. Smile when you talk to customers.

Did you know you can hear a smile? Research shows that smiling while speaking on the phone
makes a detectable difference in your tone of voice, so make sure that your team sounds happy to
talk to customers. If staff members sound dour, it is worse on the phone, since the client does not see
body language. Words and inflection are much more important over the phone than face-to-face
encounters.
 VA’s of the Future 25

7. Learn how to handle angry people.

First, don’t tell someone to calm down. No one wants to sound like a crazy person, but when a client
is that mad, they can’t help it. It’s going to sound counterintuitive, but your customer service person
should initially speak in a slightly louder voice if the customer starts out loud.

8. Answer after the first few rings.

You never want to let a call go to voicemail. In fact, you should answer within the first few rings rather
than keeping a caller waiting. Customers often grow frustrated or even hang up if they are left on the
line without assistance for too long. Even if you answer just to put them on hold while you handle
another caller, it’s better than leaving them hanging with no greeting for minutes at a time.

9. Eliminate background noise.

Background noise is extremely distracting and unprofessional. To eliminate unwanted sounds, ensure
you are in a quiet area, like a call box or private office, and don’t use the speakerphone. If your typical
workspace happens to be too loud, try taking the call elsewhere or asking those around you to lower
their voices.

10. Ask questions and take notes.

If you’re unsure who exactly the caller is and what they need from you, ask them. Make sure you jot
down information like their name, number and company, and understand exactly what they’re asking
or requesting. For instance, if they’re trying to reach someone in the company who is currently
unavailable, you’ll want to record the message they wish to relay, along with their phone number and
full name, so you can deliver it accordingly.

Mistakes to avoid on the phone with customers

Now that you know what to do when you’re on the phone with customers, here’s what not to do.

1. Don’t interrupt your customers.

This one is pretty much self-explanatory. You wouldn’t interrupt someone in a regular conversation, so
why would you interrupt your customers? Be patient and wait for them to finish before you speak fully.

2. Don’t give answers you don’t have.

It’s OK not to know something – if anything, not knowing is the start of your journey toward knowing.
Instead of giving a customer an incorrect answer, tell them you’ll put them on hold as you speak with
the right team member. Then, return with the right answer. This way, if the customer calls in again
later, they’ll encounter consistency from your team. That consistency can minimize the chance of
customer confusion and frustration.

3. Don’t lean on scripts.

Scripts can help your customer service employees know what to say when they pick up the phone –
but that’s all that scripts should do. After that, your team should use phone etiquette knowledge and
other training to intuitively navigate the conversation. An over-scripted conversation can make the
customer feel unheard and thus unsatisfied, whereas a genuine conversation can reassure and retain
the customer.

4. Don’t transfer the customer too often.

If you need to transfer someone to the right party for their inquiry, then do so. But you shouldn’t send
the customer ricocheting among different people from your team. Before transferring, you should be
100% certain you’re transferring the customer to the right team member. This way, that team member
doesn’t also have to transfer the caller. A series of transfers can confuse, overwhelm and frustrate the
customer, and that does your company no favors.

5. Don’t keep your customer service in-house if you don’t have the capacity.
Let’s say that, no matter how hard you try, your budget and time just aren’t dovetailing with your
desire to provide great in-house customer service. In that case, you can choose a call center service
to handle all your phone-based customer service. Plus, when your team isn’t on the phone all day,
they’ll get time back to handle all kinds of other business needs.
 VA’s of the Future 26

Great phone etiquette makes a great business

Creating one-of-a-kind products or providing reliable services is just the start of running a well-trusted,
successful business. How you interact with your customers, including on the phone, is also part of the
equation. Strong phone etiquette is key, whether you outsource your customer phone line to a call
center or keep it in-house. And with this guide, that etiquette will be easier to maintain during each
and every customer interaction.

1. Answer a call within three rings.If your position entails always being available to callers, you
should actually be available. That means staying focused and answering calls immediately. The last
thing you want to do is keep a customer waiting after a string of endless ringing or send them to
voicemail when you should've been able and ready to reply.As long as you're alert and at your phone
at all times — excluding breaks — this rule should be fairly simple to follow. However, we recommend
responding within three rings in order to give yourself enough time to get in the zone and prepare for
the call. Picking up the phone right away might leave you flustered.

2. Immediately introduce yourself.Upon picking up the phone, you should confirm with the person
whom they have called. In personal calls, it's sufficient to begin with a "Hello?" and let the caller
introduce themselves first. However, you want to allow the caller to know if they've hit a wrong
number, as well as whom they are speaking with.Practice answers the phone with, "Hi, this is [Your
first name] from [Your company]. How can I help you?" Your customer will be met with warmth, which
will encourage a positive start to your call. And, if it ends up being an exasperated college student
trying to order pizza, they'll at least appreciate your friendliness.

3. Speak clearly.Phone calls, while a great option for those who detest in-person interaction, do
require very strong communication skills. For one, the person on the other end of the line can only
judge you based on your voice, since they don't get to identify your body language and — hopefully —
kind smile.You always want to speak as clearly as possible. Project your voice without shouting. You
want to be heard and avoid having to repeat yourself. A strong, confident voice can make a customer
trust you and your support more. In case of bad cell service or any inability to hear or be heard,
immediately ask to hang up and call back.

4. Only use speakerphones when necessary.We all know the trials of speakerphones. It's easier for
you because you can use your hands to multitask. However, for the other caller, it's like trying to hear
one voice through a honking crowd of taxis in Manhattan — impossible and frustrating.Give your
customers your full attention, and avoid speakerphones. This will make it easier for both parties to be
heard, and it will ensure that you're actually paying attention to them. You may need to use a
speakerphone at rare occasions, such as when it's a conference call or when you're trying to
troubleshoot on the phone. While a speakerphone may be appropriate at these times, it's always
better to use a headset to remain hands-free.

5. Actively listen, and take notes.Speaking of paying attention to your customers, it's essential that
you're actively listening to them throughout the conversation. Actively listening means hearing
everything they have to say and basing your response off of their comments, rather than using a
prescribed script. This proves to your customers that you're present and are empathetic to their
inconveniences.It's helpful to take notes during support calls. You'll want to file a record
post-conversation, and notes will be immensely helpful. It also ensures that, during long-winded
explanations from customers, you can jot down the main points and jump into problem-solving without
requiring them to repeat.

6. Use proper language. A key difference between professional and personal phone calls is obvious
— the language. It might be acceptable to use slang and swears when talking on the phone with your
friends, but this kind of language can cause you to lose a customer for life.Always be mindful and
respectful when on the phone. You never know what customers might be offended by something you
say, so it's best to use formal language. It's okay to throw in humor if appropriate, but never crack a
joke that could upset a customer.

7. Remain cheerful.You never know when a customer is having a bad day. When someone is rude to
you on the phone, your immediate reaction may be to put them in your place. First, though, take a
moment to step into their shoes and recognize why they're so upset.The point is to always remain
positive and friendly, especially in the face of negativity. Your optimistic outlook may be enough to turn
 VA’s of the Future 27

a failing phone call right around. Remind yourself that the last thing your customer probably wanted
was to spend their afternoon on the phone with customer support. So, make that call the best it can
be, and it may create a loyal, lifetime customer.

8. Ask before putting someone on hold or transferring a call.There's often nothing more
infuriating than being put on hold. After waiting on hold for ten or fifteen minutes to speak with a
real-life human being, you finally get to explain your problem. Then, you're immediately put back on
hold and then transferred to someone else to whom you must re-explain the whole problem. Talk
about exhausting.However, if you must put a customer on hold or transfer their call, always ask for
their permission first. Explain why it's necessary to do so, and reassure them that you — or another
employee — are going to get their problem solved swiftly. By keeping your customer in the loop, they'll
be less inclined to complain about a long wait time.

9. Be honest if you don't know the answer. You might need to put a customer on hold or transfer
their call if the dreaded occurs — you don't know the solution. Perhaps you've tried everything you
can or simply have no idea what they're talking about. Don't panic; customer support representatives
are humans, too, and it's okay not to be the omniscient voice of reason.It's best to admit when you
don't know something, rather than making excuses or giving false solutions. However, tell them that
you're going to do everything you can to find an answer and get back to them momentarily, or find a
co-worker who does know the answer. Customers don't typically expect you to have all the solutions
at hand, but they will expect you to be transparent.

10. Be mindful of your volume.You may be so focused on your phone call with a customer that
you're barely paying attention to your present setting. When working in a call center, things can get
pretty loud. You always want to be mindful of your volume and ensure that you're not disrupting the
ability of your co-workers to speak to customers and get their work done.If you are on a call that
requires you to speak louder due to a bad connection or a hard-of-hearing customer, simply step out
of the room and speak with them separately. Your customers are always your main concern, but you
don't want to inhibit the work ethic of others in your workplace.

11. Check for and respond to voicemails.It's quite possible that a customer might reach out to you
when you're on a break or after you've left work for the day. If it's possible for you to receive
voicemails, make sure you're always checking for them. It's easy for a voicemail to slip under the
radar, but the customer won't easily forget.Start and end each day by checking your voicemail. It
takes just a few minutes and can avoid a lost customer support request. Your customers will
appreciate your prompt response, and you can get on to doing what you do best — providing
knowledgeable and friendly support.These tips should provide you and your team with basic
guidelines for phone etiquette and, if executed properly, your company should see significant
improvement in customer experience.However, there will be some interactions where these actions
may not be enough to defuse the situation. Some customer interactions will require your team to take
special measures to ensure you're meeting the customer's immediate and long-term needs. In the
next section, we'll break down a few of these scenarios and what you can do to resolve them.

Customer Service Phone Etiquette

Sometimes you may pick up the phone and immediately have to rebuild a relationship with a
customer. These cases should be scarce, but they will happen to even the best customer service
teams. It's important to use the correct phone etiquette in these types of cases to produce the most
effective outcome for both the customer and the company. To help you prepare, below are a few
common challenges that most customer service reps will face when working on the phone.

1. The customer is asking you to do something that you can't.The only "downside" to providing great
customer service is that sometimes your customers expect too much from you. When you're
constantly fulfilling their needs they may ask you to do something that you simply don't have the
power to do, or is against your company's policy. Oftentimes they're not making a malicious request,
but rather the customer thinks your team is so effective it can provide an advanced service.In these
cases, you should do your best to reset expectations for the customer regarding what your service
team can and can't do. It helps if you can provide the customer with a document or knowledge base
article that outlines your policy and answers any additional questions customers may have. While you
should be able to explain your company's policy on your own, offering a standardized document helps
 VA’s of the Future 28

build credibility for your argument. The customer knows you're not making up this response on the
spot and there's a reason for why you can't perform the requested action.

2. The customer insists on staying on the phone until their problem is resolved.Customers are
dedicated to reaching their goals and some will do nearly anything to achieve success, even if that
means staying on the phone until they get their way. This motivation can sometimes lead to stressful
situations where customers become agitated because a rep can't perform a specific action. These
cases are rare but they will happen, especially if your product is imperative for customer success.The
best measure to take in these cases is to provide proactive customer service. Pay attention to cues in
the customer's tone and vocabulary that would indicate frustration or stress. Then prevent escalation
by acknowledging the roadblock as well as how the problem impacts the customer's workflow. This
demonstrates to the customer that you have been actively listening to their request and are aligned
with their goals.If you can't defuse the situation, the next best step is to initiate a follow up plan. Let
the customer know that you would like to look into the issue further and would like to follow up via
their preferred contact method. If the customer is resistant to getting off the phone, explain how you
need to get in touch with internal references who can assist you with the issue. Make it clear that it's
in the customer's best interest to hang up the phone and follow up at a later time. If that's not possible,
contact your manager immediately to intervene with the situation.

3. The customer is demanding to speak with a manager.Many customers think that demanding to
speak with management will help resolve their case faster. In actuality, customer service managers
dictate the company's stance on customer service issues and will echo the rep's initial response if it's
in accordance with their policy. This can lead to poor customer experiences as customers will feel like
the company has failed to meet their individual needs.Instead of escalating to your manager, try to
handle the case on your own. You can certainly ask your manager for advice but make sure they're
not actively participating in the conversation with the customer. The moment you bring in your
manager you're actively admitting to the customer that you can't solve their issue on your
own.Sometimes customers will demand outright to speak with your manager. For these cases we
recommend implementing a one strike rule, meaning if a customer asks to speak with your manager
then you have one chance to prevent the escalation. Confidently tell the customer that their best
chance of resolving the issue is with your help and outline the steps you're going to take to assist
them. If that doesn't work, ask to follow up with management at a later time or directly connect them
with your manager.

4. The customer doesn't understand your explanation.Phones are great for providing immediate
support for simple and easy-to-fix issues but they can be tricky to work on when cases become more
complex. Both you and the customer have to keep track of important case details to ensure you're on
the same page throughout the troubleshooting process. In these cases, it's easy for customers to
misinterpret information and become confused about the steps you're recommending. Even if you're
providing detailed troubleshooting steps, your in-depth explanation may be too advanced for the
customer's level of product knowledge.For these scenarios, leverage customer service tools that can
help clarify your explanation. Tools like screenshares and virtual assistants provide hands-on support
and guide customers through each step of the troubleshooting process. This way you can ensure
they're following your recommendations properly and answer any questions that have at that
moment.If you don't have access to these types of tools, there are plenty of free options available for
your team. Check out this complete list of free help desk software that your team can use for its
troubleshooting efforts.

5. The customer is keeping you on the phone for too long.Customers value their time, but so do
customer service reps. Most reps have a case quota that they need to reach every day and will fall
short if they get stuck on a lengthy call. When you're dealing with 30+ calls each day, you can't afford
to be bogged down by an hour-long call. This presents you with a tricky challenge of meeting
customer needs as well as your own career goals. While you should give each customer your utmost
attention and dedication to their problem, be mindful of how long you're on the phone with a customer.
When you're no longer making any significant progress on the case, ask to follow up with them.
Explain why you need to follow up and how this will lead to a faster resolution. This measure not only
helps you reach your daily goals but will proactively demonstrate that you're being mindful of the
customer's time."
 VA’s of the Future 29

HIPAA: The Health Insurance Portability and Accountability Act

● Introduction to HIPAA
● What is HIPAA Compliance
● Protected Health Information
● Who Needs to be HIPAA Compliant?
● HIPAA Business Associates
● Am I a Covered Entity?

Introduction to HIPAA
HIPAA stands for: The Health Insurance Portability and Accountability Act which is a series of national
standards that healthcare organizations must have in place in order to safeguard the privacy and
security of protected health information (PHI). PHI is any demographic individually identifiable
information that can be used to identify a patient.

What is HIPAA Compliance

One of the most commonly asked questions we get is “What is HIPAA compliance?” so it’s important
to define compliance.

The Health Insurance Portability and Accountability Act of 1996, commonly known as HIPAA, is a
series of regulatory standards that outline the lawful use and disclosure of protected health
information (PHI). HIPAA compliance is regulated by the Department of Health and Human Services
(HHS) and enforced by the Office for Civil Rights (OCR).

The OCR’s role in maintaining medical HIPAA compliance comes in the form of routine guidance on
new issues affecting health care and in investigating common HIPAA violations.

Through a series of interlocking regulatory rules, HIPAA compliance is a living culture that health care
organizations must implement into their business in order to protect the privacy, security, and integrity
of protected health information. Learn more about how to become HIPAA compliant with Compliancy
Group’s software solutions and HIPAA compliance training.

What is Protected Health Information?

Protected health information (PHI) is any demographic information that can be used to identify a
patient or client of a HIPAA-beholden entity. Common examples of PHI include names, addresses,
phone numbers, Social Security numbers, medical records, financial information, and full facial photos
to name a few.

PHI transmitted, stored, or accessed electronically also falls under HIPAA regulatory standards and is
known as electronic protected health information, or ePHI. ePHI is regulated by the HIPAA Security
Rule, which was an addendum to HIPAA regulation enacted to account for changes in medical
technology.

Who Needs to Be HIPAA compliant?

HIPAA regulation identifies two types of organizations that must be HIPAA compliant.

Covered Entities: A covered entity is defined by HIPAA regulation as any organization that collects,
creates, or transmits PHI electronically. Health care organizations that are considered covered entities
include health care providers, health care clearinghouses, and health insurance providers.
Business Associates: A business associate is defined by HIPAA regulation as any organization that
encounters PHI in any way over the course of work that it has been contracted to perform on behalf of
a covered entity. There are many, many examples of business associates because of the wide scope
of service providers that may handle, transmit, or process PHI. Common examples of business
associates affected by HIPAA rules include: billing companies, practice management firms, third-party
consultants, EHR platforms, MSPs, IT providers, faxing companies, shredding companies, physical
storage providers, cloud storage providers, email hosting services, attorneys, accountants, and many
more.

What is a HIPAA Violation?

A HIPAA violation is any breach in an organization’s compliance program that compromises the
integrity of PHI or ePHI.
 VA’s of the Future 30

A HIPAA violation differs from a data breach. Not all data breaches are HIPAA violations. A data
breach becomes a HIPAA violation when the breach is the result of an ineffective, incomplete, or
outdated HIPAA compliance program or a direct violation of an organization’s HIPAA policies.

Here’s an example of the distinction:

A DATA BREACH occurs when one of your employees has an unencrypted company laptop with
access to medical records stolen.

A HIPAA VIOLATION occurs when the company whose laptop has been stolen doesn’t have a policy
in place barring laptops being taken off site or requiring them to be encrypted.

Under HIPAA regulation, there are specific protocols that must be followed in the event of a data
breach. The HIPAA Breach Notification Rule outlines how covered entities and business associates
must respond in the event of a breach.

What Are Common HIPAA violations?

Some common causes of HIPAA violations and fines are listed here:

● Stolen laptop
● Stolen phone
● Stolen USB device
● Malware incident
● Ransomware attack
● Hacking
● Business associate breach
● EHR breach
● Office break-in
● Sending PHI to the wrong patient/contact
● Discussing PHI outside of the office
● Social media posts

Protected Health Information

Protected Health Information, commonly known as PHI, refers to any information that relates to an
individual’s health status, medical history, or treatment. This sensitive and confidential data includes
records of doctors’ visits, prescription medication details, laboratory test results, insurance
information, and other personally identifiable information. The significance of PHI cannot be
overstated as it plays a critical role in patient care and healthcare operations while also being
governed by strict privacy laws.

In a world where we highly rely on electronic systems for storing and sharing patient data, the
importance of healthcare professionals safeguarding PHI has become more crucial than ever.

What Does PHI Stand For in Healthcare?

The PHI acronym stands for protected health information, also known as HIPAA data. The Health
Insurance Portability and Accountability Act (HIPAA) mandates that PHI in healthcare must be
safeguarded. As such healthcare organizations must be aware of what is considered PHI.

What is PHI?
You might be wondering about the PHI definition. HIPAA protected health information (PHI), also
known as HIPAA data, is any piece of information in an individual’s medical record that was created,
used, or disclosed during the course of diagnosis or treatment that can be used to personally identify
them. The meaning of PHI includes a wide variety of identifiers and different information recorded
throughout the course of routine treatment and billing. Collecting PHI is a necessary component of the
healthcare industry, and it needs to be attended to with the proper safeguards.
 VA’s of the Future 31

Examples of PHI include:

Name
Address (including subdivisions smaller than state such as street address, city, county, or zip
code)
Any dates (except years) that are directly related to an individual, including birthday, date of
admission or discharge, date of death, or the exact age of individuals older than 89
Telephone number
Fax number
Email address
Social Security number
Medical record number
Health plan beneficiary number
Account number
Certificate/license number
Vehicle identifiers, serial numbers, or license plate numbers
Device identifiers or serial numbers
Web URLs
IP address
Biometric identifiers such as fingerprints or voice prints
Full-face photos
Any other unique identifying numbers, characteristics, or codes

What is ePHI?
Electronic protected health information (ePHI) is any PHI that is created, stored, transmitted, or
received electronically. The HIPAA Security Rule has specific guidelines in place that dictate the
means involved in assessing ePHI. Media used to store data, including:
Personal computers with internal hard drives used at work, home, or while traveling
External portable hard drives
Magnetic tape
Removable storage devices, including USB drives, CDs, DVDs, and SD cards
Smartphones and PDAs
Means of transmitting data via wi-fi, Ethernet, modem, DSL, or cable network connections including:
Email
File transfers

Safeguards are critical when dealing with protected health information (PHI). There are several
measures that organizations must take to ensure the confidentiality, integrity, and availability of PHI.
One of the most essential safeguards is encryption. Encryption ensures that only authorized
personnel can access PHI using a password or other security measures.

Other safeguards include:

Firewalls
Antivirus Software
Intrusion Detection System
Regular Backups
Limiting access to PHI is equally essential. Organizations should restrict access to only those
employees who need it to perform their duties. Access controls should be in place to prevent
unauthorized access and use of PHI.

Additionally, organizations should have policies and procedures in place for granting and revoking
access rights based on job responsibilities.

Proper handling of PHI is also extremely crucial. Employees should be trained on how to handle PHI
securely, both in hard copy and electronic formats. This includes guidelines on how to create strong
 VA’s of the Future 32

passwords and how to report data breaches promptly. Regular training sessions help reinforce these
practices and keep employees updated with the best practices.

Navigating through different EHR/ EMR

What Is an EHR system?
An EHR is a digitized version of a patient’s medical chart. Examples of the data found in EHRs
include:
● Patient demographics
● Allergy information
● Medical histories
● Vital signs
● Medication histories
● Immunization records
● Diagnoses
● Lab test results
● Progress notes

An EHR system is a software program that allows for EHRs to be securely created, updated and
shared across healthcare organizations in real-time.

EHR vs. EMR: What's the difference?

An EHR and EMR are both digital versions of a patient’s chart. However, EMRs cannot be shared,
transferred or accessed as easily across healthcare organizations. EHRs, in contrast, are designed to
be shareable with everyone involved in a patient’s care, such as doctors, laboratories and specialists.

EMRs also give a narrower scope when it comes to patient data. An EMR can give you patient
demographic, diagnosis, treatment and disease progression data. An EHR contains all of the same
information, plus more detailed data regarding a patient’s medical history. EHRs give a much more
holistic view of a patient’s history than EMRs.

● Practice Fusion
1. Add Patient
2. Scheduling
3. Messaging
4. Charting
- Patient Demographics
- Chart Notes
- Documents
- Lab Reports
 VA’s of the Future 33

Add Patient using Practice Fusion

Steps:
1. Click Add Patient
2. Add Patient Info. Be very accurate with the information. Spell it out to your caller.
3. Click Save.

2. Schedule an Appointment using Practice Fusion:

Steps:
1. Go to the schedule Tab
2. Click the Patient’s preferred date and time
3. Enter the Patient Info
4. Select the type of Appointment
5. Insert a brief description on why he is coming in to schedule
 VA’s of the Future 34

2. Scheduling: How to schedule an appointment using AthenaHealth

● AthenaHealth
1. Add Patient

2. Messaging
 VA’s of the Future 35

3. Charting
- Patient Demographics

- Chart Notes
 VA’s of the Future 36

Documents

- Lab Reports
 VA’s of the Future 37

Dr. Chrono

1. Add Patient and Scheduling

2. Messaging

3. Charting

Referrals
 VA’s of the Future 38

Referral Management

Understanding the referral workflow in healthcare is crucial for ensuring the seamless transition of a
patient's care from one provider to another. Here is an overview of the typical steps involved in a
referral workflow:

1. Identification of Need for Referral:

The process begins when a healthcare provider identifies the need for a referral. This could
be due to the complexity of a medical condition, the need for specialized care, or the
necessity of additional diagnostic tests.
2. Referral Criteria and Guidelines:
Clear criteria and guidelines are established to determine when a referral is appropriate.
These criteria may include specific symptoms, diagnostic results, or the need for expertise in
a particular medical specialty.
3. Consultation with Patient:
The healthcare provider discusses the referral with the patient, explaining the reasons for the
referral and obtaining the patient's consent. During this consultation, the provider may
educate the patient about the specialist or facility to which they are being referred.
4. Referral Documentation:
The healthcare provider documents the referral details in the patient's electronic health record
(EHR) or referral management system. This documentation includes the reason for the
referral, relevant medical history, and any necessary diagnostic results.
5. Selection of Receiving Provider:
The referring provider selects a suitable receiving provider or specialist based on the patient's
needs. Factors such as the provider's expertise, availability, and location may influence this
decision.
6. Referral Authorization and Prior Approval:
If required, the healthcare provider initiates the process of obtaining authorization or prior
approval for the referral from insurance providers. This may involve submitting documentation
to justify the medical necessity of the referral.
7. Referral Coordination Team Involvement:
A dedicated referral coordination team or individual may assist in coordinating the referral.
This team ensures that the necessary information is communicated between providers,
appointments are scheduled, and any administrative tasks are completed.
8. Patient Education and Engagement:
The patient is educated about the referral process, including details about the specialist or
facility, the appointment scheduling process, and the importance of following through with the
referral.
9. Electronic Referral Submission:
The referral information is electronically submitted to the receiving provider through a secure
electronic referral system. This may involve attaching relevant documents and diagnostic
results.

Referral Intake Process

The medical referral intake process is a critical aspect of healthcare administration that involves
receiving, reviewing, and managing referrals from various sources. Here is an overview of the key
steps in the medical referral intake process:
1. Referral Source Identification:
Referrals can come from various sources, including primary care providers, specialists,
emergency departments, and other healthcare facilities. The first step is to identify the source
of the referral.
2. Referral Submission:
Referrals may be submitted through different channels, such as electronic health records
(EHRs), fax, secure messaging systems, or direct communication between healthcare
providers.
3. Referral Documentation Review:
 VA’s of the Future 39

The intake team reviews the referral documentation to ensure it contains essential
information. This includes the reason for the referral, patient demographics, relevant medical
history, and any attached diagnostic results.
4. Patient Verification:
Verify the patient's information to ensure accuracy. Confirm that the patient's details match the
information provided in the referral documentation.
5. Insurance Verification:
Check the patient's insurance information to determine coverage and identify any potential
issues related to referrals, such as the need for prior authorizations.
6. Referral Triage:
Prioritize referrals based on urgency and clinical need. Urgent cases may require immediate
attention, while non-urgent cases can be scheduled appropriately.
7. Specialist Selection:
Identify and select the appropriate specialist or healthcare provider based on the nature of the
referral and the patient's needs. Consider factors such as specialty, location, and availability.
8. Communication with Referring Provider:
Establish communication with the referring provider, if needed, to clarify any information,
request additional details, or address any concerns related to the referral.
9. Appointment Scheduling:
Schedule an appointment with the selected specialist or healthcare provider. Coordinate with
the patient to ensure the appointment aligns with their availability and urgency of the referral.

Key Considerations:
Centralized Intake System: Having a centralized system for referral intake helps ensure consistency
and coordination across the healthcare organization.
Technology Integration: Utilize technology, such as electronic referral management systems, to
streamline the intake process, reduce manual errors, and enhance communication.
Communication Channels: Maintain clear and open communication channels with referring
providers, patients, and specialists to facilitate a smooth referral process.
Compliance and Privacy: Adhere to healthcare regulations, including privacy laws such as HIPAA, to
ensure the confidentiality and security of patient information throughout the referral intake process.
Patient-Centered Care: Prioritize a patient-centered approach, ensuring that patients are informed,
engaged, and supported throughout the referral process.

Patient Engagement in Referral Process

Patient engagement in the referral process is crucial for ensuring that individuals actively participate in
their healthcare journey and receive the appropriate follow-up care. Engaging patients in the referral
process promotes understanding, adherence to recommendations, and better overall health
outcomes.

Here are strategies to enhance patient engagement in the referral process:

1. Educate Patients About Referrals:
Provide clear and comprehensive information to patients about the reasons for
referrals, the importance of specialized care, and how the process works. Ensure they
understand the potential benefits to their health.
2. Communication and Shared Decision-Making:
Foster open communication between healthcare providers and patients. Engage
patients in shared decision-making, discussing the reasons for the referral, potential treatment
options, and addressing any concerns or preferences they may have.
3. Patient-Centered Communication:
Use patient-friendly language to explain medical terms and procedures related to the
referral. Ensure that patients feel comfortable asking questions and seeking clarification.
4. Provide Written Materials:
Offer written materials or educational resources about the referral process. This can
include brochures, pamphlets, or digital resources accessible through patient portals.
5. Utilize Technology:
Leverage technology to keep patients informed. Send automated reminders and
notifications about referral appointments through text messages, emails, or mobile apps.
 VA’s of the Future 40

6. Patient Portal Access:

Ensure that patients have access to a secure patient portal where they can view
details about their referral, including the specialist's information, appointment details, and any
preparation instructions.
7. Engage Family Members or Caregivers:
Encourage patients to involve family members or caregivers in the referral process.
This support network can assist in understanding and following through with the referral plan.
8. Address Barriers to Access:
Identify and address any barriers that may hinder a patient's ability to attend a referral
appointment. This could include transportation issues, financial concerns, or language
barriers.
9. Provide Timely Feedback:
Offer timely feedback to patients regarding the results of the referral, the specialist's
recommendations, and any changes to their care plan. This helps maintain transparency and
keeps patients engaged in their healthcare.

Insurance Verification
What Is The Insurance Verification Process?
Insurance verification is a step-by-step process of contacting the insurance company to check patient
eligibility whether the patent’s health insurance company covers the required procedures. The
insurance verification process includes deductibles, policy status, plan exclusions, and other items
that affect cost and coverage and are done before patients are admitted to the hospital as it is the first
step of the medical billing process.

Skipping the insurance verification process could leave your practice with unpaid or denied health
insurance claims from the insurance companies or a patient burdened with unexpected costly medical
bills.

Reason for Claim Denials in Insurance Eligibility Verification Process

The primary reason of claim denials in insurance eligibility verification process are:
● missing patient data
● claim billing errors
● expired policies
● coverage effective
● termination dates, and
● duplicate data.

These always result in claim denials, non-payments, claim rework, delayed payments, and could
result in additional costs to the provider and the patient.

What should healthcare providers do?

Healthcare providers can eliminate setbacks by collaborating with the right outsourcing partner to
assist and support the claim process and ensure a smooth revenue cycle management.

The right partner would:

● Create streamlined and transparent processes
● Provide expert guidance
● Ensure steady cash flow
● Minimize staff workloads
● Be cost-effective
● Understand HIPAA security and CMS regulations and guidelines
● To see a comprehensive picture of insurance eligibility verification benefits, check out here.

How Does Insurance Eligibility Verification Benefit the Patient?

● It helps patients plan for their financial responsibility, minimizing stress or worry over a
surprise bill.
 VA’s of the Future 41

● It gives patients a chance to look for another, lower-cost provider or a different insurance
policy.
● It allows patients to plan for services.

Why is Medical Insurance Eligibility Verification Important?

Medical insurance verification is the first and most important step of revenue cycle management. It
helps your organization’s financial security and minimizes claim rejections. If you provide services
without verified insurance, a claim may be a loss from the beginning. Identifying service costs before a
patient receives care can also drastically improve the patient experience.

How to Verify Medical Insurance Eligibility

Medical Insurance Verification Process
1. Obtain patient demographics (name, date of birth, address, insurance provider, etc.).
2. Copy both the front and back of the patient’s insurance card.
3. Add the patient to the EHR, PM or RTE tool.
4. Add the patient’s insurance information into the EHR, PM or RTE tool.
5. Check the patient’s eligibility electronically by selecting the appropriate benefit and service
type.
6. Identify the following information from the eligibility check:
7. Who is the policy holder?
8. What is the policy effective date?
9. Does the policy have a term date?
10. Does the patient have a copay or coinsurance?
11. What are the patient’s deductible and accumulations?
12. What are the patient’s out-of-pocket maximum and accumulations?
13. Does the service require a pre-authorization?
14. Does the patient have out-of-network coverage if the provider is out-of-network with the
payer?
15. If the service requires authorization, contact the payer to determine their authorization
process.
16. Inform the patient of their financial responsibility.
17. Collect the patient’s responsibility before their scheduled appointment or treatment.

Common Insurance Payers

Aetna
BCBS Blue Cross Blue Shield Regence
BCBS – EPO, Premera, Med Advantage HMO
Medicaid (https://www.onehealthport.com/)
Cigna (https://www.onehealthport.com/)
First Choice (https://www.onehealthport.com/)
Healthnet
Humana
Kaiser
Medicare (https://www.noridianmedicareportal.com/)
Moda
Pacific Source
Providence
Tricare
United Healthcare

Prior Authorization
Prior authorization (prior auth, or PA) is a management process used by insurance companies to
determine if a prescribed product or service will be covered. This means if the product or service will
be paid for in full or in part. This process can be used for certain medications, procedures, or services
before they are given to the patient.
 VA’s of the Future 42

Healthcare.gov defines prior authorization as “approval from a health plan that may be required before
you get a service or fill a prescription in order for the service or prescription to be covered by your
plan”. The general process has many names including precertification, pre-authorization, prior
approval, and predetermination.

Services (medications, imaging studies, etc.) that require PAs need healthcare providers to obtain
approval from the patients’ health insurance before the cost of the service is covered by the company.
The process is long and can often delay patients from receiving the care they need.

How does Prior Authorization work?

Getting prior authorizations approved involves many people – primarily patients, healthcare
professionals, and the patients’ health insurance companies.

Prescription Prior Authorization

When it comes to a medication prior authorization, the process typically starts with a prescriber
ordering a medication for a patient. When this is received by a pharmacy, the pharmacist will be made
aware of the prior authorization status of the medication. At this point, they will alert the prescriber or
physician. With this notification, the physician’s office will start the prior authorization process. They
will collect the information needed for the submission of PA forms to the patient’s insurance. This can
be done via automated messages, fax, secure email, or phone.

In many cases, providers may need to directly call the insurance companies, which often requires
long periods of waiting—and maybe even persistent calls for a couple of days. There are high
possibilities of miscommunication with the patient. Patients may not be aware of what is going on or
who is involved.

Additional miscommunications can happen when trying to initiate or submit the prior authorizations.
These result from either pharmacists or doctors not starting the requests, fax machine malfunctioning,
or having difficulties getting a person on the phone. The process can take days or weeks to get
resolved with the patient having minimal information on what is happening.

Medical Prior Authorization

The prior authorization process begins when a service prescribed by a patient’s physician is not
covered by their health insurance plan. Communication between the physician’s office and the
insurance company is necessary to handle the prior authorization. In order to receive approval, the
prescriber may need to complete a form or contact the insurance company to explain their
recommendation and the need for the particular service based on patient factors that are clinically
relevant. The prior authorization is then reviewed by clinical pharmacists, physicians, or nurses at the
health insurance company.

Upon review, the request can either be approved or denied. If the prior authorization was denied by
the insurance company, the patient or prescriber may have the ability to ask for a review of the
decision and appeal the decision.

Other Options
The physician can also recommend an alternative drug or service that is covered by the patient’s
health insurance plan. In some cases, an insurance company may require patients to start on a less
costly medication or service. This is to see if the patient sees results or has a need for more costly
therapy.

If prior authorizations are just a way to “cost- control” why are they important and what is the benefit,
besides increasing profits for the insurance companies? To understand this, we must delve into the
various reasons why prior authorizations exist. In pharmaceutics, many times they are used to help
lower costs by ensuring that patients have tried using a lower cost alternative before using more
expensive medications (ie. generic) before brand medications. In addition, prior authorizations serve
as a checkpoint to verify that a patient truly needs the medication prescribed and that they are
receiving appropriate therapy.

Pharmacologic therapies that often require PAs include those that:

 VA’s of the Future 43

have many drug interactions that can lead to patient harm

have cost-effective alternatives available
its use is limited to specific health conditions and
have misuse/abuse potential.
The overarching benefit is to ensure safety, optimize patient outcomes, as well as reduce
costs to the patient and the healthcare system as a whole.

These prior authorizations save money for insurers by bypassing unnecessary or expensive treatment
options when other equally effective options exist that are included in the plan’s formulary. The
formulary includes the list of medications that are covered under an insurance plan. This process is
needed not only to ensure minimizing prescription costs, but also to verify that what is being
prescribed is medically necessary and appropriate for the patient.

Provider Opinion on Prior Authorization

Many physicians are not fond of the growing number of prior authorizations needed by insurance
companies in recent years. A 2019 study from the American Medical Association reported that 86% of
physicians believe that prior authorizations have increased in the prior 5 years.

Physicians believe that they are too time consuming and detract from time spent with patients. Some
go as far as to believe that prior authorizations are purposefully put in place to “[be] burdensome so
that physicians or patients will simply give up and use a cheaper alternative.” Providers do not
appreciate spending time to undertake administrative tasks like completing prior authorizations when
they are not properly reimbursed for the time spent or when they do not have trained staff to expedite
the process. Timothy Cordes, MD, a pediatric cardiologist, said, “[Prior authorizations] usurps the
doctors’ decisions and ultimate responsibility of care, but does not compensate for the time spent.”

Why Do Health Insurers Require Prior Authorization?

There are several reasons that a health insurance provider requires prior authorization. Your health
insurance company uses a prior authorization requirement as a way of keeping healthcare costs in
check.

By using prior authorization, your insurer wants to make sure that:

● You really need it: The service or drug you’re requesting must be truly medically necessary.
● It's recommended for your situation: The service or drug must follow up-to-date
recommendations for the medical problem you’re dealing with.
● It makes financial sense: The procedure or drug should be the most economical treatment
option available for your condition. For example, Drug C (cheap) and Drug E (expensive) both
treat your condition. If your healthcare provider prescribes Drug E, your health plan may want
to know why Drug C won’t work just as well. If you can show that Drug E is a better option, it
may be pre-authorized. If there’s no medical reason why Drug E was chosen over the
cheaper Drug C, your health plan may refuse to authorize its use. Some insurance companies
require step therapy in situations like this, meaning that they'll only agree to pay for Drug E
after you've tried Drug C with no success. The same concept applies to other medical
procedures. For example, your health plan may require prior authorization for an MRI, so that
they can make sure that a lower-cost x-ray wouldn't be sufficient.
● The service isn’t being duplicated: This is a concern when multiple specialists are involved in
your care. For example, your lung doctor may order a chest CT scan, not realizing that, just
two weeks ago, you had a chest CT ordered by your cancer doctor. In this case, your insurer
won’t pre-authorize the second scan until it makes sure that your lung doctor has seen the
scan you had two weeks ago and believes an additional scan is necessary.
● An ongoing or recurrent service is actually helping you: For example, if you’ve been having
physical therapy for three months and your doctor is requesting authorization for another
three months, is the physical therapy actually helping? If you’re making slow, measurable
progress, the additional three months may well be pre-authorized. If you’re not making any
progress at all, or if the PT is actually making you feel worse, your health plan might not
authorize any further PT sessions until it speaks with your healthcare provider to better
understand why he or she thinks another three months of PT will help you.
 VA’s of the Future 44

What Are the Rules of Prior Authorization?

Health plans each have their own rules in terms of what services need prior authorization. In general,
the more expensive the procedure, the more likely a health plan is to require prior authorization. But
some services will require prior authorization under one health plan and not under another.

In effect, a pre-authorization requirement is a way of rationing health care. Your health plan is
rationing paid access to expensive drugs and services, making sure the only people who get these
drugs or services are the people for whom the drug or service is appropriate. The idea is to ensure
that health care is cost-effective, safe, necessary, and appropriate for each patient.

Do I Need Prior Authorization in an Emergency?

If you need emergency medical care, most insurers do not require prior authorization. In some cases,
they may do the prior authorization process after you get care (retroactive).

Prior authorization requirements are also controversial, as they can often lead to treatment delays and
can be an obstacle between patients and the care they need. Particularly for patients with ongoing,
complex conditions that require extensive treatment and/or high-cost medications, continual prior
authorization requirements can hinder the patient's progress and place additional administrative
burdens on physicians and their staff.2

How Do I Get a Prior Authorization?

If you need to get prior authorization for a healthcare service, there is a process that you'll need to
follow. Here are the steps to getting prior authorization.

1. Talk to Your Provider's Office

The first thing you'll need to do to start the process of getting prior authorization is by contacting your
provider's office. They will have someone there who handles prior authorization requests. Once you
find out who you need to talk to about getting prior authorization, the next step is to find out what they
need from you. They can probably also give you a sense of what to expect during the process and
what to do if your request is denied.

2. Fill Out Paperwork

You will probably be asked to fill out some forms that your provider's office will use to submit the
request. A prior authorization form will include information about you, as well as your medical
conditions and needs.

It's very important that you fill out these forms completely and make sure that the information is
accurate. If there is information missing or wrong, it could delay your request or result in denied prior
authorization.

3. Get Organized
As you're gathering and completing paperwork as part of your prior authorization request, make sure
that you keep track of everything. You may need to refer back to the paperwork later if the request is
denied.It's also helpful to have a record of approved prior authorizations in case you need to request
another one in the future.

4. Keep Track of Dates

You may have deadlines for providing information and your provider's office will probably be working
on a timeline to submit documents during the prior authorization process. Your provider's office will
help keep you up to date, but it's also helpful if you know when things are due so you can set
reminders for yourself.

5. Have a Plan If You're Denied

Talk to your provider and their office about what you will do if your prior authorization request is
denied. You and your provider may choose to appeal the decision if you think the prior authorization
denial was not justified. If your prior authorization request is denied, the first step is to find out why. If
a simple error was to blame, it might be a quick fix.
 VA’s of the Future 45

After you've checked all the paperwork that was submitted to make sure nothing is missing and all the
information is correct, you might want to see if there are other things you could add that would help
prove the care you're asking for is needed.

What types of prescriptions require prior authorizations?

Insurance companies will most likely require prior authorizations for the following drugs:
● Brand-name drugs that have a generic available.
● Drugs that are intended for certain age groups or conditions only.
● Drugs used only for cosmetic reasons.
● Drugs that are neither preventative nor used to treat non-life-threatening conditions.
● Drugs (including those dosed at higher than standard doses) that may have adverse health
effects, possibly dangerous interactions, and/or risks for abuse or misuse.
● Drugs that are not covered by your insurance, but deemed medically necessary by your
healthcare provider.
● In many cases, prior authorizations are intended to ensure drug use is appropriate and the
most cost-effective therapy is being used. If you think your drug may require a prior
authorization, call your insurer directly to confirm.

What should I expect if my prescription needs a prior authorization?

If your prescription requires a prior authorization, the pharmacy will notify your healthcare provider.
Your provider will give the necessary information to your insurance company. Your insurer will then
decide whether or not to cover your medicine. You should hear back from your pharmacist about their
decision within two days. Remember, if you are approved, a prior authorization only lasts for a set
period of time. You will likely have to re-apply again for future fills.

What can I do if my prior authorization is denied?

Unfortunately, your insurer can deny you prior authorization, and you may be left on the hook for the
full out-of-pocket price of your drug.

If you believe that your prior authorization was incorrectly denied, submit an appeal. Appeals are the
most successful when your provider deems your treatment is medically necessary or there was a
clerical error leading to your coverage denial. One of the best ways to build your appeal case is to get
your healthcare provider’s input. Ask them about any backup documentation or medical notes that
could help you prove your prescription is medically necessary.

If that doesn’t work, your provider may still be able to help you. Some tricks to save include:

1. Getting a prescription for a higher-dose pill (which you can cut half to save on cost).

2. Filling a 90-day supply (which can be cheaper than a 30-day supply).

3. Getting free samples from your healthcare provider.

Additionally, if you are filling an expensive brand-only medication, look for any discount cards or
patient assistance programs that can help you save. And don’t forget to shop around!

Can you speed up the prior authorization process?

You may be able to speed up the process by speaking with your insurer directly. In some cases, you
may be able to submit an urgent request for a faster decision. If you need your medication urgently,
some pharmacies may let you purchase your prescription with a credit card as you wait for prior
authorization and reimburse you if your authorization is approved within a week. While you are taking
a risk, if you received prior authorization for the same drug in the past, it’s likely it will be approved
again

SOAP Notes and Charting

Introduction
SOAP notes are a highly structured format for documenting the progress of a patient during treatment
and is only one of many possible formats that could be used by a health professional. They are
entered in the patient's medical record by healthcare professionals to communicate information to
 VA’s of the Future 46

other providers of care, to provide evidence of patient contact and to inform the Clinical Reasoning
process.

SOAP is an acronym for:

S - Subjective
O - Objective
A - Assessment
P - Plan

SOAP notes were developed by Dr. Lawrence Weed in the 1960's at the University of Vermont as part
of the Problem-oriented medical record (POMR). Each SOAP note would be associated with one of
the problems identified by the primary physician, and so formed only one part of the documentation
process.

Writing a SOAP Note

While documentation is a fundamental component of patient care, it is often a neglected one, with
therapists reverting to non-specific, overly brief descriptions that are vague to the point of being
meaningless. There is no policy that dictates the length and detail of each entry, only that it is
dependent on the nature of each specific encounter and that it should contain all the relevant
information. However, the American Physical Therapy Association does provide the following
guidance on what information should be included
Self-report of the patient
Details of the specific intervention provided
Equipment used
Changes in patient status
Complications or adverse reactions
Factors that change the intervention
Progression towards stated goals
Communication with other providers of care, the patient and their family
Bear in mind that your report will be read at some point by another health professional, either
during the current intervention, or in several years time. Therefore, it is your professional
responsibility to make sure that it is well-written.

Components of a SOAP Note

Subjective
This component is in a detailed, narrative format and describes the patient's self-report of their current
status in terms of their current condition/complaint, function, activity level, disability, symptoms, social
history, family history, employment status, and environmental history. It may also include information
from the family or caregivers and if exact phrasing is used, should be enclosed in quotation marks.
The patient's goals and prior response to treatment intervention are also included. Medical information
obtained from the patient's chart can also be included if the therapist has not directly observed these
findings.

Objective
This section outlines what the therapist observes, tests, and measures. Objective information must be
stated in measurable terms. Using measurable terms helps in reassessment after treatment to
analyze the progression of the patient and hindering as well as helping factors. The objective results
of the reassessment help to determine the progress towards functional goals, and the effect of
treatment. The therapist should indicate changes in the patient's status, as well as communication
with colleagues, family, or carers.

Assessment
This is potentially the most important legal note because this is the therapist's professional opinion in
light of the subjective and objective findings. It should explain the reasoning behind the decisions
taken and clarify and support the analytical thinking behind the problem-solving process. A prioritized
problems list is generated with impairments linked to functional limitations. International Classification
of Functioning, Disability, and Health (ICF) is very useful to determine and prioritize problem lists and
thus helps to make functional physiotherapy diagnoses.
 VA’s of the Future 47

Progress towards the stated goals is indicated, as well as any factors affecting it that may require
modification of the frequency, duration or intervention itself. Adverse, as well as positive response,
should be documented in re-assessment.

Plan
The final component of the note includes anticipated goals and expected outcomes and outlines the
planned interventions to be used. Information should be provided concerning the frequency, specific
interventions, treatment progression, equipment required and how it will be used, and education
strategies. The plan also documents referrals to other professionals and recommendations for future
interventions or follow-up care.[6] The therapist should report on what the patient's home exercise
programme (HEP) will consist of, as well as the steps to take in order to reach the functional goals.
Changes to the intervention strategy are documented in this section.

Example of a SOAP Note

Current condition: COPD/pneumonia

Goals 1. Pt. will demonstrate productive cough in seated position, 3/4 trials. 2. Pt. will ambulate 150ft
with supervision, no assistive device, on level indoor surfaces.

S: Pt. reports not feeling well today, "I'm very tired".

O: Auscultation findings: scattered rhonchi all lung fields. Chest PT was performed in sitting (ant. and
post.). Techniques included percussion, vibration, and shaking. Pt. performed a weak combined
abdominal and upper costal cough that was non-bronchospastic, congested, and non-productive. The
cough/huff was performed with VC. Pectoral stretch/thoracic cage mobilizations performed in seated
position. Pt. given a towel roll placed in the back of seat to open up ant. chest wall. Strengthening
exercises in standing - pt. performed hip flexion, extension, and abduction; knee flexion 10 reps x 1
set B. Pt. performs HEP with supervision (in evenings with wife). Pt. instructed to hold tissue over
trach when speaking to prevent infection and explained the importance of drinking enough water.

A: Pt. continues to present with congestion and limitations in coughing productivity. Pt. has been
compliant with the evening exercise program, which has resulted in increased tol to therapeutic
exercise regime and an increase in LE strength. Amb. not attempted to 20 to pt. report of fatigue. Pt.
should be able to tolerate short distance ambulation within the next few days.

P: Cont. current exercise plan including CPT; emphasize productive coughing techniques; increase
strengthening exercises reps to 15; attempt amb. again tomorrow.

Template for Clinical SOAP Note Format

Subjective – The “history” section
HPI: include symptom dimensions, chronological narrative of patient’s complains,
information obtained from other sources (always identify the source if not the patient).
Pertinent past medical history.
Pertinent review of systems, for example, “Patient has not had any stiffness or loss
of the motion of other joints.”
Current medications (list with daily dosages).

Objective – The physical exam and laboratory data section

Vital signs including oxygen saturation when indicated.
Focuses on physical exams.
All pertinent labs, x-rays, etc. completed at the visit.

Assessment/Problem List – Your assessment of the patient’s problems

Assessment: A one sentence description of the patient and major problem
Problem list: A numerical list of problems identified
All listed problems need to be supported by findings in subjective and objective areas
above. Try to take the assessment of the major problem to the highest level of
diagnosis that you can, for example, “low back sprain caused by radiculitis involving
 VA’s of the Future 48

left 5th LS nerve root.”

Plan – Your plan for the patient based on the problems you’ve identified
Develop a diagnostic and treatment plan for each differential diagnosis.
Your diagnostic plan may include tests, procedures, other laboratory studies,
consultations, etc.
Your treatment plan should include: patient education, pharmacotherapy if any,
other therapeutic procedures. You must also address plans for follow-up (next
scheduled visit, etc.).

Charting
What is a medical chart?
Several terms are used interchangeably to describe a patient’s medical chart, including medical
record, health record, and patient chart. All refer to a private medical record that contains systematic
documentation of an individual patient’s important clinical data and medical history over time.
Accurate, complete medical charts enable healthcare providers to make informed and appropriate
decisions about optimal patient care.

A patient’s medical chart may contain different note types, documenting office or telemedicine visits
(encounters) and patient calls, such as:

Demographics: Name, age, contact and other details

Medications: Current and previous
Allergies: Including any potential drug-to-allergy interactions
History: Comprehensive overview of a patient’s prior visits, ongoing conditions, medications
and other factors
Family History: Immediate family’s health, causes of death, common diseases
Surgical History: Operations, dates, reports/results
Social History: Occupations (current and past), community life and more
Developmental History: Motor skills, cognitive, social/emotional, language, growth charts
Obstetric History: Number of pregnancies, outcomes, complications
Immunization Records: Vaccination dates
Habits: Drug use, smoking/drinking, sexual history, lifestyle
Consultation notes
Second-opinion notes
Progress notes
Nurse notes
Procedure notes
SOAP notes
Simple notes
Phone notes

What kind of information comprises a medical chart?

Medical charts contain documentation regarding a patient’s active and past medical history, including
immunizations, medical conditions, acute and chronic diseases, testing results, treatments, and more.
The purpose of medical charts is to provide clinicians with all necessary information to accurately
diagnose, treat, follow, and in many cases, help to prevent medical conditions, disorders, and
diseases.

For a consultation or follow-up visit, the provider’s office visit note will include note sections with all
information relevant to the patient’s care, such as the following:

Chief Complaint (CC) is a concise medical term or phrase describing the primary problem that led the
patient to seek medical attention. The chief complaint enables the provider to focus on the priority for
that day’s encounter while assessing the patient, direct the type of additional history to obtain, and
drive appropriate physical examination regarding the reported problem.
 VA’s of the Future 49

History of Present Illness (HPI) describes the progression of the patient’s present illness from initial
symptoms to present day.

Review of Systems (ROS) is a listing of questions organized by organ systems to identify

malfunctioning and disease. ROS documentation indicates the patient’s answers to such questions
vs. the physical examination note section (see below), where the provider documents what he or she
observes through seeing, hearing, or measuring during examination.1

Physical Examination may include use of a stethoscope to evaluate heart rhythm and valvular
function, percussion to detect abnormal fluid and evaluate size and borders of organs, and
determination of pulse rate, height, and weight.

Vital Signs may include the patient’s blood pressure, heart rate, respiratory rate, and more.
Results may include lab results and imaging reports received electronically from lab or imaging
interfaces, result documents uploaded to the patient’s chart, or results added to a patient’s chart
manually.

Orders may include prescriptions, referral orders, lab testing, imaging studies, specific ordered
procedures, and more.

Assessment and Plan, where the former includes diagnostic conclusions, and the latter discusses the
provider’s recommended plan for treatment.

Who has access to medical charts?

The Health Insurance Portability and Accountability Act (HIPAA)’s Privacy Rule gives individuals rights
over their health information and sets limits and rules on who is able to view and receive medical
information. In addition, HIPAA gives patients and personal representatives of patients (healthcare
proxies) the right to access their medical records from their healthcare providers and health plan upon
request. It also allows patients or healthcare proxies to ensure the accuracy of all information in their
medical records and to identify any inaccuracies that require correction. The Privacy Rule is
applicable to all forms of an individual’s protected health information (PHI), including oral, written, or
electronic.

Prescriptions
Parts of a Prescription:
Date of the prescription:
The date of the prescription should be at the top of the prescription.

Name, age, and weight of the patient:

The name, age and weight of the patient should be written in this part.
This one part is very important because of the identification purpose.

Superscription:
The superscription is the part of the prescription, containing a symbol "Rx", which means "Take
Thou"It's Latin word. English meaning you take.
Basically, the writer of the prescription is praying to the god to get the patient well soon.

Inscription:
The inscription is the part of the prescription, contains the composition of the medicine and amount of
dosage.
Example- Paracetamol 500mg ; Paracetamol 650 mg etc.

Subscription:
The subscription is the part of the prescription, contains the direction to dispense the dosage form.
The number of dosage units and the quantity to be given, written in this part of the prescription.
Example: Tab Paracetamol - 10 [ that means 10 pieces paracetamol tablet ]

Signatura:
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The signatura is the part of the prescription, contains the direction given by the writer to the patient,
how and when should the medicines be taken.
The directions are given in Latin shortcuts.
Example: "TDS" means three times a day; "BID" means "bis in die" or twice a day; "a.c" means before
a meal etc.

Signature:
The signature is the part of the prescription, containing the signature of the medical practitioner, who
writes the prescription.

What is a prescription refill?

If you’re eligible for a medication refill, that simply means you can order a new supply of your
medication when you’re running low or out of medication without having to go through your prescriber.

When your doctor writes you a prescription, he or she will decide whether or not to include refills and
how many you can have. That information can be found on the label attached to your prescription vial
or container that holds your medication.
 VA’s of the Future 51

What is a prescription renewal?

When you run out of medication refills for a maintenance medication that your prescriber has
authorized, you’ll need to get a prescription renewal. This is, in essence, a new prescription for the
same medication.

Oftentimes doctors will want to schedule periodic appointments to look over lab tests and assess how
well the medication is treating your condition before renewing your prescription. This is particularly
common when starting a new maintenance medication like blood pressure or diabetic medications.

In situations where you don’t need to be seen, you can request a prescription renewal by emailing or
calling your doctor’s office or calling your pharmacy and having them put in a request to your
prescriber for a renewal.

Medical Scribing
What is a Medical Scribe?
A Medical Scribe is a revolutionary concept in modern medicine. Traditionally, a physician's job has
been focusing solely on direct patient contact and care. However, the advent of the Electronic Health
Record (EHR) created an overload of documentation and clerical responsibilities that slows
physicians down and pulls them away from actual patient care. To relieve the documentation
overload, physicians across the country are turning to Medical Scribe services.

A Medical Scribe is essentially a personal assistant to the physician; performing documentation in the
EHR, gathering information for the patient’s visit, and partnering with the physician to deliver the
pinnacle of efficient patient care.

What does a medical scribe do?

One encounters the opinion that if you work in healthcare, you will always have a job. While many
people are concerned about losing their jobs due to technological advances, this has led to additional
jobs in the healthcare sector. For example, a medical scribe joins a doctor and enters a patient's
medical information into an electronic system. Medical scribes also retrieve information for providers
in preparation for upcoming appointments and can respond to various messages from both the patient
and the doctor upon request. Medical scribes aim to improve the efficiency of doctor-patient
encounters so that the doctor can focus solely on treatment and not office work. Because the position
provides a wide view of the medical field and a chance to work with doctors, some U.S. medical
schools suggest that prospective medical school students should first work as medical scribes to gain
relevant experience.

Skills for medical scribes

A medical scribe needs a variety of skills to perform their jobs well. Some of the most important skills
include:

Attention to detail
Medical scribes must have strong attention to detail to accurately record physicians' notes and other
patient information as well as find potential errors in patient medical histories.

Computer literacy
Most medical records are now kept on computer databases, so medical scribes work with these
computer systems to record and read patient information. They should be comfortable working with
technology and databases as well as have advanced typing and data entry abilities.

Communication
Medical scribes communicate with physicians, patients and other medical professionals daily. They
need to be able to communicate well both verbally and in written form. Medical scribes should also be
comfortable talking to others in person, over the phone and through email.

Time management
Medical scribes have to be efficient since they meet and/or speak with several patients over the day.
They also need to be able to quickly process patient information so that they can move onto the task.
Medical scribes should be comfortable working in a fast-paced environment and managing their own
time well.
 VA’s of the Future 52

Bedside manner
Since medical scribes have to work with patients daily, they must have a good bedside manner. This
means showing empathy and understanding, providing clear instructions to patients regarding
paperwork and going the extra step to help patients when they can.

How to Be a Successful Medical Scribe

1. Learn to type faster. Medical scribing requires extensive documentation of the encounter
between the patient and provider. Whether it be the history, physical, plan of care, or
disposition information, you are required to take note of every aspect of the patient's visit. For
this reason, it is crucial for you to be able to type at a high speed. Typically, scribes are
required to type at a speed of at least 60 words per minute.
2. Practice with online tools and resources, evaluating your initial typing speed in words per
minute.
3. Improve your body positioning. Do not slump, keep your posture upright.
4. Evaluate your finger positioning. Utilizing the QWERTY keyboard maximally allows faster
transcribing.
5. Practice with dictations, listen to something and try typing it out as you. This is an effective
method because ultimately you will be typing the physician's dictation.

6. Learn medical terminology. During training sessions, you will be provided with general
medical terminology. It is imperative that a scribe is able to learn and comprehend these
terms.
7. In addition to the terminology, it may be helpful to learn Latin roots, thus allowing you to
interpret terms that are unfamiliar to you. Not only will learning medical terms allow you to
transcribe faster while the physician is speaking to you, but you will be able to get a better
understanding of what the patient's course of treatment will be.
8. Understand laboratory and radiology orders. Much like learning medical terminology,
becoming familiar with common laboratory and radiology testing will allow you to get a better
sense of assessing a patient's health etiology. Providers place orders for laboratory and
radiology studies to obtain further information regarding a patient's condition. Understanding
which studies are ordered for certain cases and why will make it easier to recognize the plan
of action and medical decision-making when the physician may dictate them to you.
9. Do not ever hesitate to ask the provider why he placed certain orders on a patient or what the
results of the study indicate. Most are happy to help clarify any confusion.
10. Determine the History of Present Illness. Finally, after familiarizing yourself with all the prior
aspects, you have the knowledge and understanding to write a proper History of Present
Illness. When a patient presents to be seen by a clinician, it is imperative you document the
story just as the patient describes, but using the appropriate medical terms and descriptions.
11. The History of Present Illness is the patient's explanation of what is going on with him/her, it is
crucial that this history is well documented in order for other physicians, billing companies, or
authoritative personnel are able to understand the story.
12. Practice writing a History of Present Illness by listening to an online video of a patient
presenting to the emergency department explaining their complaints.
13. Ensure you only include information pertinent to the patient's history. Irrelevant information is
not appropriate to be placed into the History of Present Illness.
14. Listen for specific questions the physician may ask patients while they are being evaluated
and make sure to include that information in your history.
15. Always ask the physician you are working with if you are unsure of what the patient stated.
16. Always be aware of patient confidentiality. First off, it is essential that each scribe understands
the importance of patient confidentiality. In this profession, you will be exposed to a plethora
of information regarding a vast amount of people, and you are required through the law to
keep this information confidential.

Processing Referrals
What is a Patient Referral?
Generally speaking, a patient referral is a communication from one health care professional to another
— usually a specialist of some kind — requesting that they accept you as a patient to evaluate your
 VA’s of the Future 53

condition, provide a diagnosis, and/or provide treatment. A referral is a written request from one
health professional to another health professional or health service, asking them to diagnose or treat
you for a particular condition.

A referral serves several purposes.

● It ensures that the physician or health care provider is aware of the service requested and is
prepared to provide it to you.
● It streamlines new patient paperwork as your medical history and other background
information are usually provided with the referral.
● It makes patient intake, including processing insurance authorization matters, a smoother
process for all involved.

What does a referral do?

A referral provides information about you and your condition so that:
● the person you are being referred to does not have to ask so many questions
● they are aware of relevant background information
● they know exactly what they are being asked to do
● A referral is also used to indicate that the consultation or test you are being referred for is
clinically important, and that Medicare should cover at least part of the cost.

When might I need a referral?

Your health professional might refer you to someone else if:
● they believe you need expertise that the other person has
● they believe you need treatment that the other person can give
● they believe you need specialized tests or investigations
● For example, someone with pregnancy complications may be referred to an obstetrician, or a
person with cancer may be referred to an oncologist and surgeon.

You are likely to need a medical referral or request to:

● see a specialist
● get x-rays or use other diagnostic imaging services
● use pathology services, such as blood tests
● What information does a referral include?
● The referral should include:

How long does a referral last?

Most referrals from general practitioners (GPs) to specialists are limited to 12 months. They should
cover a single course of treatment for the condition you are being referred for. The referral covers all
the visits to the specialist for that condition.

If you need continuing care, such as for a chronic (continuing) health condition, the GP can write a
referral beyond 12 months or for an indefinite period. If you develop a new condition, you will need a
new referral for that condition. Referrals from specialists and consultant physicians to other specialists
are limited to 3 months unless the patient is admitted to hospital.

Who can make a referral?

Referrals can be made by doctors, dentists and certain allied health professionals — nurse
practitioners, midwives, physiotherapists, osteopaths, optometrists and psychologists. Some services
can only be ordered by a particular specialist. For example, you may need a referral by a specialist for
certain types of MRI scans.

When are Referrals Necessary? And Why Do I Need a Referral to See a Specialist?
Usually, referrals from doctors are recommended to ensure you receive the right care from the right
health care specialist at the right time. The question, however, when are patient referrals needed will
depend on your insurance policy terms.

Your primary care provider (PCP) is usually your first line of defense when it comes to your
healthcare. Typically an internist, general practitioner (GP), family medicine physician, pediatrician,
physician assistant, or nurse practitioner, your PCP is the person you go to first when you have a
 VA’s of the Future 54

medical complaint or are seeking a check-up. While PCPs are trained to take care of most routine
health matters, they will sometimes determine that another practitioner can best handle a particular
issue. In situations like this, they will refer you to another provider.

Sometimes doctors’ referrals are made for routine preventive care — such as being referred to a lab
for a blood draw. Other times, medical referrals are for diagnosis and treatment. For instance, if you
are experiencing ongoing foot pain, your PCP might refer you to a podiatrist or an orthopedist
specializing in foot and ankle issues.

Often, patients request that their PCP refer them to a specialist. They may prefer seeing someone
that the PCP knows and trusts — rather than relying on word-of-mouth referrals from friends or
Google reviews — and they might need the referral to be in-network with their insurance company to
pay for the visit.

What is the Patient Referral Process?

Depending on your insurance provider’s requirements, the typical primary care to specialist referral
process goes something like this.

● You consult with your PCP about your need for a referral. This conversion may be initiated by
either your doctor or you, depending on the reason for the referral.
● Your PCP determines the type of specialist that will best meet your needs. Often, this will be
someone in their practice network, someone they have worked with before, and/or someone
you have had a prior relationship with or have a preference to see.
● Your PCP’s office will send a referral form to the specialist, which typically includes your
relevant medical records, the reason for the referral, and, where applicable, the parameters of
treatment. For instance, you might be referred for eight weeks of physical therapy to manage
shoulder pain. In some instances, a care navigator can book an appointment for you.
● After your visit for diagnosis, treatment, or therapy, the specialist will send a report to your
PCP detailing the results of your visit, your diagnosis, if applicable, and their
recommendations, if any, for follow-up or further treatment. This type of communication
ensures that you have continuity of care.

How Do Referrals Work Under Different Insurance Plans? Does Insurance Cover Provider
Referrals?
Whether, to what extent, and how your insurance plan covers or requires referrals depends on the
type of policy you have and the details of the particular plan. The following provides, in general terms,
an overview of how different types of insurance plans treat physician referrals.

HMO and POS network plan. If you are on an HMO (health maintenance organization) or POS (point
of service) network plan, you will likely be required to obtain a PCP referral before seeking the
services of a specialist. The plan would have assigned you a PCP when the plan took effect. Check
with this provider before proceeding with a specialist, or you may have to pay for the visit yourself.

PPO or EPO network plan. Suppose you are on a PPO (preferred provider organization) or EPO
(exclusive provider organization) network plan. In that case, you can probably seek specialist services
on your own without requiring a referral. However, you must choose a provider in your plan’s network
if you want to take advantage of lower costs and co-pays. Out-of-network providers can be costly, and
some may not be covered under your plan.
Original Medicare (Part A, Part B). As long as the provider accepts Medicare, your specialist visit will
be covered under Parts A&B.
Medicare Advantage (Part C). Be careful when choosing a physician under Medicare Advantage
plans. Many of these plans operate like HMOs, so you need a PCP referral to see a covered
specialist. Others operate like PPOs, so you can choose your own provider, but you will want to
ensure they are in the specified plan network. Under some private fee-for-service plans (PFFS),
assuming the doctor accepts Medicare, you will have to pay up to 15% of the charges out of pocket.