Practice Management

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Practice management
Psychiatry/patient selection
Pediatric consent

    • <18yo have to have consent from at least one parent (unless emancipated)
      • Alternatives to a procedure are a part of informed consent, nature of surgery, diagnosis,  indications, benefits, consequences, side effects, risks, consequences of alternatives, probability of success
      • Minors should not be put at risk due to parents religious beliefs, “bloodless” surgery still provides physician with emergency transfusion if life depends on it
    • emancipation – marriage, military service, financial independence, living apart from parents, parenthood
      • legally able to consent for medical procedures


    • preoccupation with perceived flaws that seem minor/slight to most others
    • repetitive behavior or mental acts related to appearance concerns
    • preoccupation causes significant distress and impaired daily function
    • Eating disorders may be seen but are not critical to diagnosis
    • BDD is most commonly associated with depression (75%)
    • Psychological contraindications to surgery: when success is dependent on goals (job promotion marriage etc), must be seen frequently post-operatively

statistical power

    • a measure of the number of subjects in comparison to the effect size, test size, and power of the test
    • can determine a sample size or verify a nonsignificant result after data collection. 
    • ideal power = 80%

P value

    • the probability that the result happened by chance
    • a low P value (usually <0.05) means that there’s a less than 5% chance that the observed results happened due to chance/sampling variation. so you can feel confident rejecting the null hypothesis.

Types of tests

    • categorical variables –> pearsons chi-squared test
    • numeric variables –> regression analysis
    • independent numerical, dependent categorical –> ANOVA
    • nonparametric tests – wilcoxon rank-sum, kruskal-wallis test
    • Numerical and dependent categorical variables: unpaired T tests and ANOVA


    • Type I: you think theres an effect when there really isnt (rejecting the null hypothesis when it is true)
      • Protect by setting a higher alpha
    • Type II: you think theres no effect but actually there is
      • Increase your power
    • Type III: rejecting the null hypothesis for the wrong reason
    • Type IV: incorrect interpretation of a correctly rejected hypothesis

Levels of studies

    • I – high quality blinded RCT with adequate power, or systematic review of these
    • II – lower quality RCT, prospective cohort, or systematic review of these
    • III – retrospective cohort study, case-control study, or systematic review of these
    • IV – case series
    • V – expert opinion consensus, case report, or evidence based on physiology principles/bench research

Specificity – the ability of a test to correctly classify an individual as disease free (ratio of those classified as disease free and total number of healthy patients)
Sensitivity – the ability of a test to correctly classify an individual as diseased
Ratio of those classified as having the disease over the total number of sick patients
Charity – 

    • participating in charity cannot imply or provide a financial incentive to have a procedure
    • does not imply understanding of a performance or procedure for which the patient has not been medically evaluated yet
    • injectables like botox are appropriate
    • no procedures, no implants

Certificate of need – to coordinate planning of new services while controlling costs for production/building
Advertising board eligible while still seeking initial certification – only ok for 8 years

    • after that, boards every 10 years


    • computerized provider order entry is the preferred method for entering orders, otherwise a written or verbal with readback
    • CMS EHR Enrollment gives you 1% penalty adjustments below existing medicare/medicaid reimbursements for failure to participate in the meaningful use of certified EH technology on a yearly basis
    • Meaningful use of EMR = increasing the ability of health care systems to protect patient medical information in compliance with HIPAA regulations- using the approved EMR systems to their full potential in order to provide optimization of health care data documentation to improve the quality of health care
      • using the approved EMR systems to their full potential in order to optimize documentation to improve the quality of care delivered
      • improve quality/safety/efficacy/reduce disparities
      • engage patients and families
      • improve care coordination
      • improve population/public health
      • ensure privacy/security protection for PHI

Universal protocol for preventing wrong site, wrong procedure and wrong person surgery

    • preop patient identification by three members of the team
    • preoperative marking of the surgical site
    • final time-out prior to surgery or procedure

Government in Sunshine act – open payments – CMS publishes med devices/pharmaceutical rep payments of over a certain amount to physicians
ADA – requires that reasonable accommodations are provided by businesses and in public areas to allow people with disabilities to participate in daily activities

    • HIPAA (health insurance portability and accountability act): rights including restricting information, inspecting records, amending records, can audit disclosure of records (covers health plans, clearinghouses, and providers)
      • Can waive IRB/HIPAA if preparing research protocol or performing research on someone who has died
      • IRB approval must have deidentified information-strip records of any identifying information or have statistician approve small contribution to identification
      • Requires standardization of electronic health care
      • Disclosures: per request of patient, for treatment or payment, to individuals identified by patient, incidental disclosure, limited data set with removal of identifiers, public interest groups
    • PHI
      • name, address, birth date, SSN
      • past/present/future physical or mental health condition
      • provision of health care to the individual
      • payment for the provision of health care to the individual
      • For payment, must sign HIPAA wavers in matters of dispute , cannot send documentation without signed consent
    • PHI can only be shared between two treating healthcare professionals in a confidential/encrypted communication not at risk of breach or theft
      • To store patient photos on computer must be encrypted using an approved process
    • privacy official is a responsibly body for privacy in an organization – can range from an individual who functions as the privacy official at a small practice, to a full time position


    • Ambulatory surgery requirements: AAASF, must be board certified (with any board), general anesthesia requires 12-24 hours of oversight, must have unrestricted privileges within 30 minutes , pediatric patients need to be PALS trained by one member, inspected q3 years
    • “new patient” – hasn’t been seen in the same specialty in the same practice in 3yr
    • Use of a medical assistant does not increase medico-legal risk, witness is not part of the integral consent process
    • Cannot use ASPS logo until board certified
    • Office based procedures: need appropriate drugs, resuscitation, and intubation equipment, defibrillator
    • Disciplinary action: charging exorbitant fees (especially in emergencies), charity events in which surgery is performed, endorsement compensations, false pictures- not typical results or photographic techniques that misrepresent
    • Potential hires: do not ask about disabilities, age, arrests, children, religion, country of origin, race, child care
    • If not treating patient, must obtain verbal consent to view and share information
    • When you prescribe medication to friend, friend becomes patient and must document this encounter


    • near miss – unplanned event that does not result in injury/illness/damage but has the potential to do so
    • look-alike sound-alike medication error – giving or prescribing wrong medication because it looks or sounds similar

Health insurance

    • physician bills for an amount.
    • insurance decides how much the service is worth, and that is how much the physician will get. (the difference is not considered debt or anything)
    • the actual payment may come partially from the insurance company and partially from the patient, depending on their “co-pay” agreement.


    • A – hospitalizations, SNF, hospice (usually included if you are over 65 or if you are under 65 but collect social security benefits)
    • B – provider and related services ie doctors, PT, labs, equipment, mental health
    • C – additional approved private health insurance
    • D – prescription drug coverage
    • Medicare payments: difference of bill and payment is considered contractural adjustment and services are paid in full (physician agrees to accept payment according to medicare fee schedule)- payment from medicare and copayment

ACA – must offer 10 essential health benefits

    • outpatient care, ER visits, hospitalization, maternity/newborn, mental health/substance use treatments, prescription drugs, rehab + equipment, lab tests, preventative services and chronic disease care, pediatric services including dental and vision.
    • does not cover adult dental or vision
    • Insurance companies do not cover elective cosmetic procedures, patient must be billed separately; must inform OR when switching to cosmetic portion of procedure

Core competencies

    • interpersonal and communication skills
    • medical knowledge
    • patient care and procedural skills
    • professionalism
    • systems based practice  (ACGME milestone)
      • coordinating patient care within health systems, cost awareness, patient advocacy, interprofessional development


    • Cameras: for optimal reproducible digital photographs and pre- and post op need matching anatomical landmarks, same camera/lens/lighting/patient position
      • Grid pattern, 2 lenses, single lens with 50-60mm marco, 90-105 focal for facial, 2 light sources, sky blue uncluttered background

ACAPS Inservice exam questions 2015-2020

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