AAO-HNSF Certificate Program for Otolaryngology Personnel

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OTO Tech Training Workbook May 2024

CERTIFICATE PROGRAM FOR OTOLARYNGOLOGY PERSONNEL

OTO Tech Training Workbook

May 2024 © American Academy of Otolaryngology-Head and Neck Surgery Foundation

Welcome to the Course

The American Academy of Otolaryngology—Head and Neck Surgery Foundation is pleased to offer the Certificate Program for Otolaryngology Personnel (CPOP), a training program for otolaryngology office personnel to learn basic hearing testing. In this curriculum you will learn to function as part of the hearing healthcare team under the supervision of your sponsoring otolaryngologist. This program is psychometrically sound and designed to be a highly cost-effective way to increase office efficiency. OTO Techs will allow audiologists the opportunity to provide advanced hearing and balance services and focus on challenging patients. For practices with no audiologist, basic testing can be provided at the time of a visit. One emphasis of the training is for the trainee to understand the issues involving scope of practice. CPOP requires a self-study module followed by hands-on practical training and a six-month period of clinical experience supervised by an otolaryngologist. This notebook will serve as your manual to guide you through the program. The notebook contains the program outline and the self-study module. Once you have completed the self-study module you will receive the material for the Practicum and the Clinical Experience, including the procedure checklists and logbook, to add to your notebook. In the spring of 2001, the AAO-HNS/F Board of Directors approved the initiation of the Coalition for Hearing and Balance. Under the direction of the Coalition for Hearing and Balance CPOP was developed by leading otolaryngologists and audiologists including Thomas J. Balkany, MD; James C. Denneny III, MD; Eileen M. Giaimo, MEd, MHA, CPC; Maureen T. Hannley, PhD; Kathy Harvey, MsED, CCC-A, HIS; Paul R. Lambert, MD; Fred D. Owens, MD; Robert T. Sataloff, MD; Caren Sokolow, MA, CCC-A; Hinrich Staecker, MD, PhD; and Stephen J. Wetmore, MD.

Course Overview

Phase 1: Independent Study Timeline: March 1 through April 24, 2024

This component will familiarize participants with basic understandings and theory necessary to perform as an OTO Tech. Participants will complete a set of readings and an open book online exam covering the readings. (provided 2-months in advance)

1. Overview 2. Required Textbook and Readings 3. Open Book Exam

Phase 2: Practicum: Hands-on Workshop Timeline: May 3-5, 2024

This component will provide hands-on instruction covering the basic hearing tests conducted by an OTO Tech. Each skill will be taught around a procedure checklist for performing the skill. Practicum participants will demonstrate their understanding of the component objectives taught.

1. Overview 2. Instructional Method 3. Practice Training Sign-oƯ Sheet (Table 1) 4. Workshop Presentations a. Welcome/Overview b. Basic Science of the Ear and Hearing

c. Ear and Hearing d. Physics of Sound e. Audiometric Evaluation f. Tymponometry g. Audiometric Technique h. Masking i. Certificate Program for Otolaryngology Personnel (CPOP) Review j. Knowing Your Limitations k. Awareness of Other Hearing Tests and Hearing Aids

_______________________________________________________________________________________________________________________________ © Copyright 2024. AAO-HNSF Certificate Program for Otolaryngology Personnel Course

Program Goals The basic OTO Tech certificate training program originated with the American Academy of Otolaryngology— Head and Neck Surgery Foundation. The AAO-HNSF received comments from otolaryngologists on the increasing need for basic hearing and balance testing services and the lack of appropriately trained staff. To meet the needs of the membership the AAO-HNSF created a training program for an OTO Tech. After completion of this program, successful candidates will be able to perform all the objectives listed, under the supervision of a licensed physician. Audience This training program is suggested for clinic office personnel who may be called upon or who are interested in basic in-office hearing testing. It is also suggested for medical assistants, licensed practical nurses, registered nurses, nurse practitioners, physician assistants, and hearing instrument specialists who may wish to begin work with a physician (or meet continuing education requirements). Residents may also benefit from this training program. Program Components This training program has three components. Each component must be completed before the next component begins. Participants who successfully complete all three components will be issued a Certificate of Completion by AAO-HNSF. Benefits of the OTO Tech Training and Certificate  Increased ability to perform objectives under supervision of licensed physician.  Enhanced potential career development.  Increased patient safety.  Decreased liability. About The American Academy of Otolaryngology—Head and Neck Surgery, Inc. (AAOHNS), and its Foundation, the American Academy of Otolaryngology—Head and Neck Surgery Foundation, Inc. (AAO-HNSF), are two separate and independent organizations, each incorporated in the District of Columbia.

The Foundation is a non-profit, educational organization, designated as a 501(c)(3) association by the IRS. The Academy is designated as a 501(c)(6) non-profit association by the IRS.

www.entnet.org

Component 1: Independent Study Timeline: March 1 through April 24, 2024 (online)

Component 2: Practicum Timeline: May 3-5, 2024 (In-person)

This component will provide hands-on instruction covering the basic hearing tests conducted by an OTO Tech. During this two and a half-day training session, participants will also gain an understanding of basic vestibular tests. Each skill will be taught around a procedure checklist for performing the skill. Practicum participants will demonstrate their understanding of the component objectives taught. Component 3: Supervised On-the-Job Clinical Experience May 6 through October 10, 2024 (On the job - 6 months to complete) This component will give participants who have completed the Independent Study and Practicum real world experience. Participants will perform the basic hearing skills as an OTO Tech and be evaluated using the skills checklists under the supervision of a licensed physician.

Textbook and Readings 1. OTO Tech Program Scope of Practice 2. HIPPA Tips 3. Principles of Good Medical Record Documentation 4. Article Reprints

Certificate of Completion All participants who successfully complete the Independent Study, Practicum, and On-The-Job Clinical Experience will receive a Certificate of Completion from the AAO-HNSF.

Phase 3: Supervised On-the-Job Clinical Experience May 6 through October 10, 2024 (6 months to complete)

This component will give participants who have completed the Independent Study and Practicum real-world experience. Participants will perform the basic hearing skills as an OTO Tech and be evaluated using the skills checklists under the supervision of a licensed physician.

1. Overview 2. Method: What is expected between the Otolaryngologist and OTO Tech 3. Hearing Testing Logs

References 1. OTO Tech Program Scope of Practice 2. HIPPA Tips 3. Principles of Good Medical Record Documentation 4. Article Reprints

Table of Contents

A. Introduction

1. Program Goals 2. Program Components 3. Textbook and Readings 4. Certificate of Completion 5. About AAO-HNSF

B. Independent Study 1. Personal roles in relation to a physician and audiologist 2. Professional relationship with patients 3. Patient confidentiality 4. Need for physician diagnosis

Basic Hearing 1. Basic anatomy and physiology of the ear 2. Types of hearing loss patterns and variations 3. Basic physics of sound and hearing 4. Basic causes of hearing loss and audiometric patterns 5. Basic types and purpose of hearing tests a. Tuning fork tests b. Pure tone air and bone conduction c. Speech audiometry i. Speech Recognition Threshold ii. Speech Recognition Threshold with masking iii. Word Recognition iv. Word Recognition with masking d. Tympanometry 6. Existing problems that preclude accurate testing and the need for referral to the otolaryngologist

7. Awareness of other hearing testing a. Otoacoustic emission testing b. Evoked potential response c. Pseudo-hypoacusis testing 8. Hearing aids and devices

C. Practicum

Objectives

Basic Hearing: Lecture, Preview, Demonstration, and Practice 1. Documentation of patient case history and exam

a. Review patient history b. Summary of patient visit 2. Perform a basic examination of the ear a. Evaluate external auditory canal b. Recognize existing problems that preclude accurate testing and the need for referral to the otolaryngologist c. Perform tuning fork testing 3. Perform basic hearing testing a. Pure tone air and bone conduction testing with and without masking b. Perform speech audiometry testing i. Speech Recognition Threshold ii. Speech Recognition Threshold with masking iii. Word Recognition iv. Word Recognition with masking c. Tympanometry

D. Supervised On-The-Job Clinical Experience 1. Develop and maintain a professional relationship a. Patients b. Professionals 2. Record history results 3. Perform a basic examination of the ear a. Evaluate external auditory canal b. Perform tuning fork tests

4. Provide patient instructions/education regarding basic hearing testing 5. Provide basic hearing tests a. Perform pure tone air and bone conduction testing with and without masking b. Perform speech audiometry testing i. Speech Recognition Threshold ii. Speech Recognition Threshold with masking iii. Word Recognition iv. Word Recognition with masking c. Perform tympanometry 6. Demonstrate understanding of personal limitations as a technician 7. Demonstrate when appropriate to ask for assistance 8. Maintain On-the-Job Training Checklist 9. Complete log of hearing cases

OTO Tech – Scope of Practice

OTO Techs are trained to perform hearing tests and related functions under the supervision of an otolaryngologist – head and neck surgeon. Skill sets assigned are at the discretion of the supervising otolaryngologist, who defines the role of the OTO Tech in his or her oƯice. The well-trained OTO Tech must possess a general understanding of the anatomy of the ear, the physics of sound, and the types and causes of hearing loss. OTO Tech training provides technicians with an understanding of how to review patient history, document the patient’s present illness and exam, summarize the patient visit, perform a basic examination of the ear, provide patient instructions regarding hearing testing, perform tuning fork tests, perform pure tone air and bone conduction testing with and without masking, perform speech reception threshold testing with and without masking, perform word recognition testing with and without masking, and perform tympanometry. The well-trained OTO Tech will ensure that all tests are performed accurately and that results are recorded in the patient file. It is not the role of the OTO Tech to provide interpretation of the test results or a diagnosis. The word diagnosis derives from the Greet meaning “through knowledge.” The otolaryngologist, by virtue of medical school and at least five subsequent years of medical/surgical residency, is uniquely qualified to evaluate all data collected and arrive at a diagnosis. A medical diagnosis is made only by a licensed physician after a complete medical history, physical evaluation, and review of appropriate audiologic, laboratory, and imaging studies. Correct treatment or rehabilitation of hearing loss is dependent upon an accurate diagnosis achieved by thorough knowledge of the auditory system disorder and clinical experience with the various treatments available for medical disease, which may range from amplification to medication to surgical intervention. Audiologists identify and assess disorders of the hearing and balance systems of children and adults. Audiologists select, fit, and dispense amplification systems such as hearing aids and related devices, program cochlear implants, and provide instruction, rehabilitation, and counseling services to enhance human communication. A graduate (doctorate or master) degree is required for practice.

Textbook and Readings

Required

Martin, Frederick N., and Clark, John Greer. Introduction to Audiology, 13th ed, 2018. Columbus: Pearson

OTO Tech Scope of Practice: Alexandria, VA: American Academy of Otolaryngology—Head and Neck Surgery Foundation, 2004.

Bradford, Vicki. How Patient’s Perceive Service. Pittsburgh, PA: Association for Otolaryngology Administrators, OTO’s Scope, December 2001.

Privacy Protection Codes of Conduct. Pittsburgh, PA: Association for Otolaryngology Administrators. OTO’s Scope, May 2003.

Benoit, Cathy. Another View of HIPAA. Association for Otolaryngology Administrators, OTO’s Scope, May 2003.

Murphy, Brian J. Principles of Good Medical Record Documentation. Journal of Medical Practice Management, Greenbranch Publishing, LLC, 2001.

Recommended

DeRuiter, Mark, and Ramachandran, Virginia. Core Clinical Concepts in Audiology Basic Audiometry Learning Manual, 3rd Edition. San Diego, California: Plural Publishing, 2021

Hannley, Maureen. Basic Principles of Auditory Assessments. San Diego: College-Hill Press, Inc., 1986.

Sandlin, Robert E., ed. Hearing Instrument Science and Fitting Practices, second ed. Livonia, MI: National Institute for Hearing Instruments Studies, 1996.

Sataloff, Robert Thayer, and Sataloff, Joseph. Hearing Loss, 3rd ed. New York: Marcel Dekker, Inc., 1993.

Reprinted with permission from The Journal of Medical Practice Management , Copyright 2001, Vol. 16 #5 pages 258-260, Greenbranch Publishing LLC, PO Box 208, Phoenix MD 21131, 800-933-3711, www.mpmnetwork.com. For a sample issue of the Journal please contact ncollins@greenbranch.com. Principles of Good Medical Record Documentation Although the world of medicine seems to be changing and progressing with each day, one thing that has not changed is the need for good documentation. The medical record of today does not only reflect your care of the patient, but has become a communication tool to a wide variety of players. Everyone seems to looking at your records, from colleagues to HMOs, and in the worst-case scenario, a plaintiff’s attorney. This article will help show why good documentation is so important not only for good medical care, but if needed, as a defense tool if faced with a medical malpractice claim. Brian J. Murphy

Key words: Documentation; malpractice; SOAP method; medical record keeping.

INTRODUCTION

Have you ever thought of making an addition to a patient medical record, even as innocent as to clarify a point, document a conversation, or write down examination findings that you may have forgotten at the time of the visit? Alterations such as these, unless done in a timely fashion, may render your case indefensible. Complete medical records are the cornerstones of quality health care. They provide information used for planning the patient’s continuum of care; serve as a communication vehicle with other health care providers; are used for quality assurance; support billing and reimbursement; and are the best tools for the defense of a medical malpractice claim.

BASICS OF MEDICAL DOCUMENTATION

Throughout the course of a medical malpractice case, the most important piece of evidence will be the medical record. The loss of many cases can be directly attributed to poorly maintained medical records or lack of documentation in the patient’s medical record. If your records are accurate, legible, and well organized, they will greatly increase your chances of successfully defending a malpractice suit.

Throughout a medical malpractice case, the most important piece of evidence will be the medical record.

The “Golden Rule” in documentation is “If it isn’t written down, you didn’t do it.” Every entry should stand independently and provide enough information so a new care giver reviewing the medical record would know exactly what the patient was being seen for, their course of treatment, and the physician’s plan of action. The following guidelines

will help to ensure complete entries in the medical record and point out common stumbling blocks found in documenting in patient’s charts.

“If it isn’t written down, you didn’t do it.”

CHARTING METHODS

There are several charting methods used by health care providers to help assure that appropriate information is included in the record. The SOAP method is a commonly used format to help promote complete and consistent entries.

SOAP format is as follows:

S= Subjective data: the patient’s description of their symptoms or condition.

O= Objective findings: the physician’s findings or observations about the patient.

A= Assessment: the physician’s assessment of the subjective complaints and objective findings.

P= Plan: the physician’s plan for current and future treatments.

Your notes should contain only objective documentation. Objective documentation supports your diagnosis and treatment plan. Subjective documentation is not supported by facts and can be open to interpretation.

Important points that must be included in every record:

• The patient’s name should be on every page in the record.

• The pages should be secured in chronological order.

• A problem list, current medication list, including the dosage and an allergy sticker, should be in the chart.

• Vital signs must be documented for each visit.

• Progress notes must be legible, complete, and signed and dated by the physician.

• Use only universally known abbreviations.

• Informed consent conversations including risks, benefits and treatment alternatives discussed and any associated forms noted in the chart.

• Discharge instructions including time and action specific instructions, for example, “if the pain is not better in 2 days, call me”.

All lab results need to be signed and dated by the physician. Abnormal lab results must be addressed. Follow-up actions taken or advice given to the patient should be clearly documented in the record. If no follow-up is documented in the medical record, the plaintiffs’ attorney will conclude that these results were either missed or ignored by the physician.

All lab results need to be signed and dated by the physician.

Entries in the medical record should be made in a timely manner. This holds true especially if there is an adverse or unsatisfactory outcome. A malpractice claim may arise from this event. Never rely solely on your memory or memories of your witnesses. Your record may become the only means of keeping the facts straight. A good “rule of thumb:” the history and physical should be recorded within 24 hours of admission, surgical notes should be entered immediately following a procedure, and a full surgical report should be made within 24 hours. Telephone and/or verbal orders should be countersigned within 24 hours. Document all follow-up conversations on previously discussed problems, recommendations, and test results. A patient’s compliance or noncompliance, missed appointments, and follow-up telephone calls also must be documented. Patient education needs to be documented as well. The record must show that the patient was fully and carefully instructed on possible adverse reactions to new medications, potential long-term effects of the medications prescribed, limitations/restrictions following surgery, and exercise regimens. It is also important to document that the patient acknowledges that they understand this information. If family members of the patient are included and present during the review and discussion of educational materials, this needs to be documented as well. If a correction must be made in the medical record, strike a single line through the error and make the corrections, ensuring that they stay in chronological order, and initial and date the correction. Striking a single line through the error allows for the original entry to remain legible. Under no circumstances should you cross out completely or use correction fluid to remove an error. Never squeeze corrections between lines or in the margins of the medical record. If more space is needed, you can add an addendum to the record. Label it as “addendum,” add the current date that it is being written, and reference the original entry. If your office utilizes dictation services for the medical record, you must proofread them carefully prior to signing and dating them. Don’t assume that what you dictated is what is going to appear on the transcribed note. Corrections to Medical Records

If a correction must be made in the medical record, strike a single line through the error and make the corrections . . .

In addition, you should never make corrections after a complication that has occurred, copies of the original record have been released, or a lawsuit has been filed. Never destroy or remove any of the pages from the patient’s medical record.

Other Documentation

All patient contacts need to be documented. This includes scheduled appointments, office visits, hospital visits, missed appointments, no-show appointments, and telephone conversations. Telephone conversations that need to be documented include: patients calling with any clinically relevant information, calling for prescription refills, advice or instructions given, completions or concerns expressed by the physician or the patient, follow-up

efforts, and test results. The pertinent information that must be recorded at the time of the call includes the name of the caller, date and time of the call, what was reported, any instructions or advice given, and any action taken. To assist in keeping track of this information, a small telephone pad could be kept by your telephone or in your pocket. Telephone messages recorded either in the office or after hours need to be added to the respective patient’s chart the following day. Avoiding omissions of information and time gaps is very important. Information most noticeably missing from medical records includes progress and/or operative reports, history and physical, vital signs, discharge summaries, and informed consent. Time gaps in the chart pose a serious defense problem. When these gaps occur, it allows the plaintiff’s attorney to focus on the missing times and claim negligence. If you are using preprinted forms, all blanks need to be filled in with either your findings or N/A or DNA. Remember, “If it’s not written down, you didn’t do it.” Documentation of medical mishaps should show that you promptly identified the complication, responded appropriately, and aggressively treated the complication and maintained appropriate follow-up. This documentation should include both positives and negatives. Documentation of medical mishaps should not include matters with legal implications or matters that are of no value to patient care or are related to risk prevention activities (i.e., completion of an incident report or notification of insurance personnel or your attorney). Finger pointing or blaming of others, otherwise known as “Chart Wars” (I called the patient’s internist four times, but as usual he did not call me back) does not belong in the chart. These remarks in the chart allow the plaintiff’s attorney to pit one doctor against the other. It also provides the plaintiff’s attorney with a potential “expert” witness testifying against you along with driving indemnity amounts higher. “Red Flags” include using words such as “mistake,” “error,” “inadvertent,” etc. In addition, conflicts or arguments with other treating physicians or nursing staff do not belong in the medical record. Tampering or changing a medical record to cover-up a mistake or mishap or to add new information in light of a pending lawsuit can be disastrous. You may feel the need to alter the record for errors in judgment that may not have been negligent and are not subject to recovery of damages. This includes inserting self-serving comments or observations. With the advances in chemical and spectroscopic examination of medical records, plaintiff attorneys are now using ink analysis to uncover alterations and determine accurate time dating of entries. Armed with this information, chemists are able to determine when the ink was produced and if it matches other entries in the medical record. Any appearance of changes or a cover-up will destroy your credibility in the eyes of the judge and jury, not to mention that you risk the possibility of non-renewal of your medical malpractice insurance by your carrier. Documentation of medical mishaps should not include matters with legal implications . . . Changes to Medical Records

Tampering or changing a medical record . . . can be disastrous.

BENEFITS OF GOOD MEDICAL RECORD DOCUMENTATION

Providing good medical record documentation aids in the quality assurance process. Having well-organized and legible medical records allows the auditor a clear picture of the patient’s complaint, symptoms, procedures, or actions to alleviate or eliminate the patient’s illness or injury, status of the patient condition following treatment, and final outcome. A well-maintained medical record facilitates the collection of data that may be useful for education or research within your practice. Nurses and allied health professionals can also look to the medical record to evaluate the progress of the patient as it pertains to their individual care plan. Contractual obligations with Health Maintenance Organizations (HMO’s), require good documentation to ensure that consistent service is being given to the patient. Medical records can also be used by HMOs to verify pertinent information such as the site of service, medical necessity, and diagnostic, therapeutic, or ancillary services. Good documentation holds true for ICD-9-CM codes on health insurance claim forms and with reimbursement from Medicare and Medicaid. If you were to be challenged by an auditor for your billing practices by the HMO, Medicare, or Medicaid, the medical record could be used to validate the services rendered. Poor documentation or coding may increase the potential for an intensified audit that might place you in jeopardy of losing you participation in Medicare and Medicaid. As we have seen, there are many reasons for maintaining complete, detailed, and legible medical records. They paint a picture of why the patient has come to see you, your clinical findings, and your treatment plans. They are your best protection in a malpractice suit and show justification in your billing procedures if you were to be audited. The most important concept to remember in striving for good medical record documentation is, “If you didn’t write it down, you didn’t do it.” n * Risk Management Specialist, Illinois State Medical Insurance Services, Inc., 20 N. Michigan Avenue, Suite 700, Chicago, IL 60602; phone: 800-782-4767; E-mail: Murphy@ismie.com. The material in this article was prepared by the Risk Management Division of the Illinois State Medical Inter-Insurance Exchange under the direction of its eight-member Physician Risk Management Committee. CONCLUSION

aoa news

T he following general codes of conduct will reasonably ensure that the chance of incidental disclosures is minimized. This list is not exhaustive. It should serve to help create a culture that fosters the protection of individually identifiable health information from inappropriate use and disclosure. n Minimize the risk of others overhearing • Speak in lowered tones • Talk apart from others when sharing patient history information (PHI) n Do not use patient names in public places (hallways, elevators). n Do not leave patient charts, or other sources of PHI in places that are accessible to unauthorized individuals. Privacy Protection Codes of Conduct

HIPAA

Tips 3

n Remove papers containing PHI from fax machines or copiers in a timely manner. Give the information to the appropriate person. n Place patient charts facing wall in box outside room. n Escort non-employees in areas where PHI might be accessible. • Pharmaceutical Reps wait in waiting room until physician is available. n Limit information disclosed on answering machines to the minimum necessary. n Limit information disclosed to patient’s family members, friends, or other persons regarding an individual’s care, even when the individual is not present.

n Limit information disclosed when calling out patient name in waiting room. n Make sure that computer monitors cannot be viewed by unauthorized individuals. n Never share your login id and/or password. The Health Insurance Portability and Accountability Act is here to stay. Any checklists and established standard operating procedures that can be developed to assist physicians and staff in complying are efforts well spent.

another view of HIPAA

Today a health care provider may do business with a number of health plans, each with its own version of forms, code sets, or identifiers required for payment. The Health Insurance Portability and Accountability Act (HIPAA) sets out to change that. Under HIPAA all health plans are required to use the standards set forth in this regulation. The standards established by HIPAA will enable administrative efficiency all across the healthcare industry. Physicians’ offices will have more time for patients and spend less time on paperwork. We will have standard data, which will yield better data; and better data will yield better information. This in turn will yield better health outcomes for all of us. All covered entities must comply with the HIPAA privacy regulations. It is true that if you are a 100% paper office, you are not a “covered entity” and thus do not have to comply with the HIPAA rules. But is that a good business decision? We live in a competitive market. The organizations that embrace HIPAA as a business opportunity and prepare their organization for the future of health care will be able to realize the benefits. Other industries have gone through their own standardization processes. For example, the banking and grocery industries have embraced technology and standardization to streamline their costs. There was a time when we had to wait in line for a bank teller to process all of our transactions, but now we can use the telephone, computer, or A TM for access to our accounts 24 hours a day, 7 days a week. We are also capable of processing transactions from any banking institution, not just the one where we first opened our account.

Do you recall when the stock clerks worked all night to fill the grocery shelves with priced items, and the cashier had to type in the price of each item into a cash register? Then when we checked-out we received a generic receipt. Now every item is identified by a bar code and is scanned for an itemized receipt. In fact the grocery stores have streamlined the process to the point that we can checkout ourselves via the V-SCAN-it stations. These changes have proved to provide customers greater benefits while saving the industry’s service providers money in the long run. In both of these industries and many more, the use of electronic standards have revolutionized the way business is conducted. Implementing HIPAA will require the health care industry to change many long used and familiar business processes. Change is difficult for most people, and HIPAA is about change. A change of this magnitude will not happen overnight. It will take time, hard work, communication and possibly investment capital. It is a fact that we live in a competitive market, so I encourage you to consider HIPAA as the first step in preparing your organization for the future of healthcare. Can you afford not to? Cathy Benoit, MBA

CBenoit@cms.hhs.gov HIP AA Coordinator Centers for Medicare & Medicaid Services — Atlanta Regional Office

Printed with permission

12 MAY 2003

Oto’s Scope

Learning Guide Worksheet

The learning guide worksheet outlines each learning objective and its related list of readings (with designated pages) to its associated test questions. For each objective, complete the reading(s) and answer the questions related to that objective in the online exam.

Make sure you read the materials carefully. If you do not feel you know the answer to the questions review the materials again and discuss the questions with your supervising otolaryngologist.

To pass the Independent Study component, you must receive an exam score of 80% or higher. You have 3 attempts to achieve the minimum passing score.

Learning Objectives

List of Readings

Test Questions

1. Understand personal roles in relation to a physician and audiologist

OTO Tech Scope of Practice

1, 2, 3,

2. Understand professional relationship with patients

“How Patient’s Perceive Service”

4, 5, 6

3. Understand patient confidentiality

“Privacy Protection Codes of Conduct”; “Another View of HIPAA”; and “Principles of Good Medical Record Documentation”

7, 8, 9, 10, 11, 12

4. Understand need for physician diagnosis

Martin and Clark, (2003) Ch. 9 - 11 OTO Tech Scope of Practice

13, 14, 15,

Hearing

5. Understand basic anatomy and physiology of the ear

Martin and Clark, (2003) Ch. 2, Ch. 9; Ch. 10; Ch. 11; and CD-ROM Martin and Clark, (2003) Ch. 2; Ch. 4, Ch 9 - 11, and CD-ROM

16, 17, 18, 19

6. Understand types of hearing loss patterns and variations

20, 21, 22, 23, 24, 25, 26, 27, 28

7. Understand basic physics of sound and hearing

29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 78, 79, 80 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 81, 86 54, 55, 56, 57, 58, 59, 60, 61, 62, 82, 83, 84, 85, 87, 88, 89, 90, 91

Martin and Clark, (2003) Ch. 3

8. Understand basic causes of hearing loss and audiometric patterns

Martin and Clark, (2003) Ch. 9 - 11

9. Understand basic types and purpose of hearing tests

Martin and Clark, (2003) Ch. 2, Ch. 4

Tuning fork tests

▪

Pure tone air and bone conduction

▪

Speech audiometry

▪

Tympanometry

▪

10. Understand existing problems that preclude accurate testing and the need for referral to the otolaryngologist 11. Become aware of other hearing testing:

Martin and Clark (2003) Ch. 9 - 10

63, 64, 65, 66

Martin and Clark, (2003) Ch. 6, pp. 161-163 (evoked potential testing), Ch. 6, pp. 163 164 (Electrocochleography); Ch. 13, pp. 346-358 (Pseudo-Hypoacusis testing); Ch. 12, pp. 313-342 (Central auditory testing); Ch. 6, pp. 158-161 (Otoacoustic emission testing); Ch. 8, pp. 192-194.

67, 68, 69, 70, 71

Otoacoustic emission testing

▪

Evoked potential response Electrocochleography (EcoG) Central auditory testing Pseudo-Hypoacusis testing

▪

12. Become aware of hearing aids and devices

72, 73, 74, 75, 76, 77

Martin and Clark, (2003) Ch. 14

Open Book Exam

Personal Roles in Relation to a Physician and an Audiologist (Questions 1-3)

1. In patients with complex hearing disorders, the personnel most fully trained to perform routine and specialized hearing tests are generally:

a. Licensed neurotologists b. Licensed otologic nurse clinicians c. OTO Techs d. Certified audiologists

2. The patient's diagnosis is made by a:

a. Licensed physician b. Licensed otologic nurse clinician c. OTO Tech d. Certified audiologist

3. A well-trained OTO Tech follows standard office procedure regarding the distribution of hearing test results to referring phyisicans.

a. True b. False Professional Relationship with Patients (Questions 4-6)

4. Actions that should be avoided during patient visits are:

a. Projecting coldness, apathetic responses, and acting in a condescending manner b. Protecting the patient's privacy, and escorting patient to the testing considerate fashion. c. Engaging conversations, providing information on tests, and updates on delays d. Demonstrating care and respect and greeting patient in friendly manner

5. Essential to developing a patient's positive opinion of a provider is to:

a. Ignore patient's input and be condescending b. Be disrespectful, unfriendly, and uninformative c. Be unaware of the patient's case and not provide visual and verbal information d. Know the patient, listen to concerns, and provide quality information

6. On their first visit patients, especially elderly patients, should be addressed by their first name to make them feel welcome.

a. True b. False

Patient Confidentiality (Questions 7-12)

7. Patient charts should face out with detailed information on the patient and the reason for today's visit facing out for the physician to quickly scan prior to entering the exam room.

a. True b. False

8. Disclosure of patient information should be limited when:

a. Left on an answering machince b. Discussing an individuals care with family members, friends, or others when the individual is not present c. When calling patients in the waiting room d. All of the above

9. HIPAA is the acronym for a Congressional Act that establishes certain patient rights. What does the acroynm stand for?

a. Health Insurance Program for Americans Act b. Health Improvement Plan of America Act c. Health Insurance Portability and Accountability Act d. Health Improvement Project for the Aging Act

10. A chart/test that lacks any of the following data is an incomplete medical record and a potential liability hazard.

a. Patient name b. Date of visit c. Legible notes d. All of the above

11. Documentation of an office visit should avoid:

a. Opinions of referring physician b. Condemnation of prior treatment c. Criticism of patients inusurance coverage d. All of the above

12. For legal and billing purposes, a visit or test that is not documented is a visit or test that did not occur.

a. True b. False

Need for Physician Diagnosis (Questions 13-15)

13. The word diagnosis is derived from the Greek meaning:

a. Through Medicine b. Through Knowledge c. Through Experience d. Through Training

14. The cause of a hearing loss can always be determined on an audiogram.

a. True b. False

15. The well-trained OTO Tech performs tests accurately and

a. Dictates a report to the insurance company b. Only verbally communicates results to the otolaryngologist c. Records results in patient file and/or on audiogram d. Provides patient with a diagnosis of ear disease

Basic Anatomy and Physiology of the Ear (Questions 16-19)

16. Which of the following anatomical sites is least likely to cause ear pain?

a. Cervical spine b. Temporal mandibular joint (TMJ) c. Throat d. Ear canal

17. Sound waves striking the tympanic membrane cause the ossicles to vibrate. The vibration of the footplate of the stapes against the oval window creates sound by causing a traveling wave in the:

a. Utricle b. Superior semi-circular canal c. Cochlea d. Lateral semi-circular canal

18. In order to visualize the tympanic membrane, the angle of the external auditory canal must be straightened. In examining the adult ear with an otoscope, the technician should:

a. Pull the pinna down and forward b. Pull the pinna up and backward c. Press in on the tragus d. Avoid traction on the ear in patients who have had a stapedectomy

19. A patient who complains of altered taste sensation following middle ear surgery may demonstrate an injury to the scala tympani

a. True b. False

Types of Hearing Loss Patterns and Variations (Questions 20-28)

20. Which of the following symptoms is least likely to be associated with a hearing loss?

a. Tinnitus b. Headaches c. Dizziness d. Ear fullness

21. A decrease in the strength of a sound is called:

a. Conductive hearing loss b. Sensorineural hearing loss c. Air conduction d. Attenuation

22. With a sensorineural hearing loss, the air conduction results are:

a. Better than bone conduction results b. Equal to bone conduction results c. Worse than bone conduction results d. Unrelated to bone conduction results

23. When air conduction testing shows a hearing loss and bone conduction testing shows normal hearing, the loss is a:

a. Conductive hearing loss b. Sensorineural hearing loss c. A mixed hearing loss d. A central hearing loss

24. The Schwabach Test:

a. Compares the hearing sensitivity of a patient's left and right ears b. Compares the hearing sensitivity of the patient with that of the examiner c. Is easily administered if the patient has a mixed loss d. Stimulates only one ear at a time

25. Tuning fork tests are:

a. Always accurate in aiding in diagnosis b. Dependent upon many variables c. Difficult to perform d. Necessary to determine sensorineural hearing loss

26. Tests by air conduction measure sensitivity:

a. Throughout the entire hearing pathway b. From the inner ear to the brain c. Through the middle ear only d. Through the inner ear only

27. The air-bone gap (ABG) on an audiogram shows:

a. The amount of sensorineural involvement only b. The total hearing loss c. The amount of conductive involvement d. The bone conduction responses only

28. Bone conduction test results:

a. May be better than air conduction test results b. May be worse than air conduction test results c. May be the same as air conduction test results d. All of the above

Basic Physics of Sound and Hearing (Questions: 29-38)

29. Which of the following is/are necessary to the production of sound?

a. A vibrating body b. An elastic medium c. Propagation d. All of the above

30. If a paper machine is producing 90dBspl, and a second machine next to it and produces 90dBspl, the resulting sound will be:

a. 90dBspl b. 93dBspl c. 96dBspl d. 99dBspl

31. The threshold of pain at the ear is reached at:

a. 60 dBspl b. 20,000 mPa c. 40,000 mPa d. 140 dBspl

32. The effect of traveling sound waves on particles in the elastic medium is:

a. They disperse particles in a circular distribution b. The increase the speed of particle transmission c. They decrease the speed of particle transmission d. They result in areas of compression and areas of rarefaction of air pressure

33. 0 dB HL = no sound.

a. True b. False

34. The "pitch" of a sound is related to frequency and the "loudness" is related to amplitude.

a. True b. False

35. An increase from 10 dB to 20dB HL, is in effect, doubling the intensity.

a. True b. False

36. The longer wavelengths of lower frequency sounds of vowels move more easily around obstructions than do the shorter wavelengths of higher frequencies contained in many of the consanants of speech.

a. True b. False

37. Vowels have higher frequency sound waves than consanants.

a. True b. False

38. 0 dB represents:

a. A just audible sound b. No sound c. A soft rustle of leaves d. A whisper at 10 feet

Basic Causes of Hearing Loss and Audiometric Patterns (Questions: 39-53)

39. Which of the following is not a cause of obstruction of the external auditory canal?

a. Cerumen b. Exostosis c. Otosclerosis d. Treacher Collins Syndrome

40. Otolsclerosis can be associated with all of the following symptoms except:

a. Hearing loss b. Tinnitus c. Dizziness d. Paracusis willisii

41. Meniere's disease is characterized by sudden attacks of all except:

a. Vertigo b. Memory loss

c. Tinnitus d. Vomiting

42. Damage to which of the following structures is least likely to cause a sensorineural hearing loss?

a. Labyrinth b. Auditory nerve c. Ossicles d. Organ of corti

43. A positive fistula test occurs when negative and positive insufflation of air in the ear canal causes:

a. Temporary hearing loss b. Dizziness c. Pain d. Coughing

44. The "net effect" of hearing protection is:

a. To reduce the intensity of sound reaching the inner ear b. To change the frequency components of the noise c. To shut out all sound d. To trap the noise in the ear canal

45. The structure usually damaged by intense noise is:

a. Brain stem b. Inner ear c. Middle ear d. Balance mechanism

46. Long-term intense noise exposure produces:

a. Conductive losses b. Mixed losses c. Sensory losses d. None of the above

47. Repeated episodes of temporary threshold shift (TTS) eventually lead to:

a. Otosclerosis b. Greater degree of TTS c. Conductive hearing loss d. Permanent threshold shift (PTS)

48. Hearing loss due to aging is called:

a. Presbycusis b. Meniere's diseases c. Diplacusis d. Hyperacusis

49. If impacted cerumen occludes the external auditory canal, prior to performing an audiogram the OTO Tech should:

a. Gently remove the cerumen with a cerumen spoon (curette) b. Irrigate the ear with a sterile ear syringe and basin

c. Prescribe use of Debrox ear wax system for one week and then retest the patient d. Comply with standard operating procedure recommended by the otolaryngologist

50. Conductive hearing loss may result from problems which affect the transmission of sound through the external and middle ear. This is true of all of the following except:

a. Otitis externa b. Otosclerosis c. Serous otitis media d. Presbycusis

51. Sensorineural hearing loss has multiple causes, which require full otologic evaluation. All of the following may result in sensorineural hearing loss except:

a. Presbycusis, occupational hearing loss, diabetes mellitus b. Meningitis, ototoxic drugs, syphilis c. Mumps, rubella, head trauma, ear surgery d. Cerumen impaction, otitis externa, congenital atresia of the ear canal

52. Hearing loss as a result of noise exposure is most likely to be evident at frequencies between 3,000 Hz. And 6,000 Hz.

a. True b. False

53. Excessive cerumen in the ear canal will usually cause what looks like a sensorineural hearing loss. a. True b. False

Basic Types and Purpose of Hearing Tests (Question 54-62)

54. If a tuning fork test reveals that the Weber test lateralizes to the left ear, and the Rinne test reveals that bone conduction is better than air conduction on the left, these findings most commonly are produced by:

a. Left sensorineural hearing loss b. Left conductive hearing loss c. Right sensorineural hearing loss d. Right conductive hearing loss

55. The pure tones generally used in audiometric testing are:

a. 250, 500, 1000, 2000, 3000, 4000, 5000, 6000, and 8000Hz b. 500, 1000, 2000, 4000, 6000 and 8000Hz c. 100, 250, 500, 1000, 2000, 4000, and 8000Hz d. 250, 500, 1000, 2000, 3000, 4000, 6000, and 8000Hz

56. The test procedure for air conduction pure tone testing for the first ear is:

a. 1000, 2000, 3000, 4000, 6000, 8000, 1000 (repeated), 500, and 250Hz b. 250, 500, 1000, 2000, 3000, 4000, 6000, and 8000Hz c. 1000, 2000, 3000, 4000, 6000, 8000, 500, and 250Hz d. 250, 500, 1000, 2000, 3000, 4000, 6000, 8000, 250 (repeated), and 500Hz (repeated)

57. Each frequency should be tested using brief bursts of sound no longer in duration than:

a. 2 sec. b. 4 sec. c. 5 sec. d. 6 sec.

58. For bone conduction pure tone testing, it is necessary to test the frequencies from:

a. 500 - 6000Hz b. 1000 - 4000Hz c. 250 - 8000Hz d. 250 - 4000Hz

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