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SEVENTH EDITION

ADMINISTRATIVE
PROCEDURES FOR
MEDICAL ASSISTING
Kathryn A. Booth, RN-BSN, RMA (AMT), RPT, EFR, CPhT, MS
Total Care Programming, Inc.
Palm Coast, Florida

Leesa G. Whicker, BA, CMA (AAMA)

Central Piedmont Community College—Retired
Charlotte, North Carolina

Terri D. Wyman, CPC, CMRS, CMCS, AS

Baystate Wing Hospital
Palmer, Massachusetts

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C H A P T E R 1 4 U N I T F O U R

Telephone Techniques 270 Administrative Practices

Introduction 271
14.1 Telecommunications Equipment 271 C H A P T E R 1 6
14.2 Effective Telephone Communication 274
14.3 Telephone Etiquette 275 Schedule Management 315

14.4 Types of Incoming Calls 277 Introduction 316

SKILLS VIDEO: Managing a Prescription Refill 279
14.5 Managing Incoming Calls 282
14.6 Taking Complete and Accurate Phone Messages 284
14.7 Placing Outgoing Calls 285
PROCEDURE 14-1: Using a Video Relay Service with an
American Sign Language Interpreter 287
PROCEDURE 14-2: Renewing a Prescription by Telephone 288
PROCEDURE 14-3: Screening and Routing Telephone Calls 289
PROCEDURE 14-4: Handling Emergency Calls 289
PROCEDURE 14-5: Retrieving Messages from an Answering
Service or System 290
ELECTRONIC HEALTH RECORDS: 14.01 Create an Electronic
Telephone Encounter 293
ELECTRONIC HEALTH RECORDS: 14.02 Create an Urgent
Electronic Telephone Encounter 293
ELECTRONIC HEALTH RECORDS: 14.03 Complete a
Prescription Refill Request 293
PRACTICE MEDICAL OFFICE: Admin Check In: Office
Operations 293
C H A P T E R 1 5
Patient Education 294
Introduction 295
15.1 The Educated Patient 295
15.2 Learning and Teaching 296
15.3 Teaching Techniques 296
15.4 Patient Education Materials 297
15.5 Promoting Health and Wellness Through Education
15.6 The Patient Information Packet 303
15.7 Patient Education Prior to Surgery 306
PROCEDURE 15-1: Creating Electronic Patient Instructions 309
PROCEDURE 15-2: Identifying Community Resources 310
PROCEDURE 15-3: Locating Credible Patient Education
Information on the Internet 310
PROCEDURE 15-4: Developing a Patient Education Plan 311
PROCEDURE 15-5: Outpatient Surgery Teaching 311
ELECTRONIC HEALTH RECORDS: 15.01 Document
16.1 The Appointment Book 316
16.2 Applying the Matrix 317
16.3 Appointment Scheduling Systems 319
16.4 Organizing and Scheduling Appointments 324
16.5 Special Scheduling Situations 328
16.6 Scheduling Outside Appointments 330
SKILLS VIDEO: Scheduling Outpatient Surgical Appointments 330
SKILLS VIDEO: Scheduling Inpatient Surgical Appointments 331
16.7 Maintaining the Practitioner’s Schedule 331
PROCEDURE 16-1: Creating an Appointment Matrix 334
PROCEDURE 16-2: Scheduling Appointments 334
PROCEDURE 16-3: Completing the Patient Appointment
Card 334
PROCEDURE 16-4: Placing Appointment Confirmation Calls 335
PROCEDURE 16-5: Scheduling Outpatient Surgical
Appointments 335
PROCEDURE 16-6: Scheduling Inpatient Surgical
Appointments 336
ELECTRONIC HEALTH RECORDS: 16.01 Maintain a
Provider’s Schedule Matrix in an EHR 339
ELECTRONIC HEALTH RECORDS: 16.02 Add a Patient to the
Schedule in an EHR 339
ELECTRONIC HEALTH RECORDS: 16.03 Cancel a Patient’s
Appointment in an EHR 339
ELECTRONIC HEALTH RECORDS: 16.04 Document
Administration of Surgical Instructions 339
PRACTICE MEDICAL OFFICE: Admin Check Out: Work Task
Proficiencies 339
301
C H A P T E R 1 7
Insurance and Billing 340
Introduction 341
17.1 Basic Insurance Terminology 341
17.2 Private Health Plans 342
17.3 Government Plans 347
17.4 Payer Payment Systems 354
17.5 The Claims Process: An Overview 356

Administration of Patient Education 314 SKILLS VIDEO: Requesting Prior Authorization 358
ELECTRONIC HEALTH RECORDS: 15.02 Document 17.6 Preparing and Transmitting the Healthcare Claim 362
Administration of ­Pre- and Post-Operative Instructions 314 17.7 Transmitting Electronic Claims 371
PRACTICE MEDICAL OFFICE: Admin Check Out: Interactions 314 17.8 Insurer Processing Claims and Payments 372

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PROCEDURE 17-1: Verifying Workers’ Compensation
Coverage 374
PROCEDURE 17-2: Submitting a Request for Prior
Authorization 375
PROCEDURE 17-3: Completing the CMS-1500 Claim Form 375
PROCEDURE 17-4: Tracking Insurance Claims Submissions 377
ELECTRONIC HEALTH RECORDS: 17.01 Create and Submit
an Insurance Claim 380
PRACTICE MEDICAL OFFICE: Admin Check in: Work Task
Proficiencies 380
C H A P T E R 1 8
Diagnostic Coding 381
Introduction 382
18.1 The Reasons for Diagnosis Codes 382
18.2 Why ICD-10-CM Is Necessary 383
18.3 An Overview of ICD-10 385
18.4 Coding with ICD-10 388
18.5 External Cause of Injury and Health Status Codes 391
18.6 Synopsis of ICD-10 Coding Guidelines by Chapter 395
SKILLS VIDEO: Locating an ICD-10-CM Code 401
PROCEDURE 18-1: Locating an ICD-10-CM Code 401
PROCEDURE 18-2: Locating a Health Status (Z) Code 402
PROCEDURE 18-3: Locating an External Cause Code 402
ELECTRONIC HEALTH RECORDS: 18.01 Assign a Diagnostic
Code to an Office Visit - A 405
ELECTRONIC HEALTH RECORDS: 18.02 Assign a Diagnostic
Code to an Office Visit - B 405
ELECTRONIC HEALTH RECORDS: 18.03 Maintain the
Diagnosis Code Database in an EHR 405
PRACTICE MEDICAL OFFICE: Admin Check Out: Office
Operations 405
C H A P T E R 1 9
Procedural Coding 406
Introduction 407
19.1 The CPT Manual 407
19.2 General CPT Guidelines 409
19.3 Evaluation and Management Services 415
19.4 Surgical Coding 417
19.5 Using the CPT Manual 421
SKILLS VIDEO: Locating a CPT Code 421
19.6 The HCPCS Coding Manual 422
19.7 Coding Compliance 422
PROCEDURE 19-1: Locating a CPT Code 424
PROCEDURE 19-2: Locating a HCPCS Code 424
PROCEDURE 19-3: Entering CPT and ICD Codes into an EHR
Program 425
ELECTRONIC HEALTH RECORDS: 19.01 Assign a Procedure
Code to an Office Visit - A 427
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ELECTRONIC HEALTH RECORDS: 19.02 Assign a Procedure
Code to an Office Visit - B 427
ELECTRONIC HEALTH RECORDS: 19.03 Maintain the
Procedure Code Database in an EHR 427
PRACTICE MEDICAL OFFICE: Admin Check Out: Work Task
Proficiencies 428
C H A P T E R 2 0
Patient Collections and
Financial Management 429
Introduction 431
20.1 The Medical Practice as a Business 431
20.2 Medical Office Accounting Methods 431
20.3 In-Office Transactions 436
20.4 Standard Billing Procedures 440
20.5 Standard Collection Procedures 442
SKILLS VIDEO: Posting Charges, Payments, and
Adjustments 444
20.6 Laws That Govern Credit and Collections 445
20.7 Credit Arrangements 447
20.8 Common Collection Problems 450
20.9 Banking and Negotiable Instruments 450
20.10 Preparing a Bank Deposit 454
20.11 Reconciling the Bank Statement 454
20.12 Electronic Banking 456
20.13 Accounts Payable and Managing Disbursements 458
PROCEDURE 20-1: Posting Charges, Payments, and
Adjustments 460
PROCEDURE 20-2: Using the Superbill as Bill/Receipt 460
PROCEDURE 20-3: Posting a Nonsufficient Funds (NSF)
Check 461
PROCEDURE 20-4: Processing a Payment Resulting in a
Credit Balance 461
PROCEDURE 20-5: Processing Refunds to Patients 462
PROCEDURE 20-6: Preparing an Age Analysis 462
PROCEDURE 20-7: Referring an Account to a Collection
Agency and Posting the Payment from the Agency 463
PROCEDURE 20-8: Completing a Truth in Lending Statement
(Agreement) 463
PROCEDURE 20-9: Making a Bank Deposit 464
PROCEDURE 20-10: Reconciling the Bank Statement 465
PROCEDURE 20-11: Setting Up the Disbursements Journal 466
ELECTRONIC HEALTH RECORDS: 20.01 Record a Patient
Payment 469
ELECTRONIC HEALTH RECORDS: 20.02 Post Insurance
Deposits to the Practice Account 469
ELECTRONIC HEALTH RECORDS: 20.03 Create a Patient
Statement 469
ELECTRONIC HEALTH RECORDS: 20.04 Create an Age
Analysis Report 469
CONTENTS ix
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ELECTRONIC HEALTH RECORDS: 20.05 Handle a Returned 57.4 Common Disorders 509
NSF Check 469 57.5 Less Common Disorders 512
ELECTRONIC HEALTH RECORDS: 20.06 Process a Patient SKILLS VIDEO: Caring for a Patient Who Is Vomiting 512
Payment 469 SKILLS VIDEO: Performing Cardiopulmonary Resuscitation
ELECTRONIC HEALTH RECORDS: 20.07 Issue a Patient (CPR) 514
Refund 469 57.6 Common Psychosocial Emergencies 516
PRACTICE MEDICAL OFFICE: Admin Check Out: Work Task 57.7 The Patient Under Stress 516
Proficiencies 469
57.8 Educating the Patient 517
57.9 Disasters and Pandemics 517
57.10 Bioterrorism 518
U N I T N I N E
PROCEDURE 57-1: Stocking the Crash Cart 520

Medical Assisting Practice PROCEDURE 57-2: Performing an Emergency

Assessment 521
PROCEDURE 57-3: Foreign Body Airway Obstruction in a
C H A P T E R 5 6 Responsive Adult or Child 521
PROCEDURE 57-4: Foreign Body Airway Obstruction in a
Practice Management 471
Responsive Infant 523
Introduction 472 PROCEDURE 57-5: Controlling Bleeding 524
56.1 Organizational Design 472 PROCEDURE 57-6: Cleaning Minor Wounds 524
56.2 Managing the Medical Practice 474 PROCEDURE 57-7: Caring for a Patient Who Is Vomiting 525
SKILLS VIDEO: Petty Cash 476 PROCEDURE 57-8: Assisting During a Chemical
56.3 Human Resources and Practice Management 478 Disaster 525
56.4 Being a Leader 481 BODY ANIMAT3D: Burns 527
56.5 Risk Management and Quality Assurance 482 PRACTICE MEDICAL OFFICE: Clinical: Privacy and
SKILLS VIDEO: Completing an Incident Report 484 Liability 528
56.6 Handling Payroll 484
C H A P T E R 5 8
56.7 Calculating and Filing Taxes 488
PROCEDURE 56-1: Preparing a Travel Expense Report 493
Preparing for the World of Work 529
PROCEDURE 56-2: Preparing an Agenda 493
PROCEDURE 56-3: Completing an Incident Report 494 Introduction 530
PROCEDURE 56-4: Generating Payroll 494 58.1 Training in Action 530
ELECTRONIC HEALTH RECORDS: 56.01 Assign Access 58.2 Obtaining Professional Certification 534

Rights to an Employee 497 58.3 Preparing to Find a Position 535

PRACTICE MEDICAL OFFICE: Admin Check Out: Privacy and 58.4 Interviewing 541
Liability 497 58.5 On the Job 545
PROCEDURE 58-1: Résumé Writing 546
PRACTICE MEDICAL OFFICE: Admin Check Out: Work Task
C H A P T E R 5 7 Proficiencies 548

Emergency Preparedness 498

Introduction 499 A P P E N D I C E S
57.1 Understanding Medical Emergencies 499 I Diseases and Disorders   A-1
57.2 Preparing for Medical Emergencies 500 II Prefixes, Suffixes, and Word Roots in Commonly Used
SKILLS VIDEO: Performing an Emergency Assessment 502 Medical Terms   A-19
57.3 Accidental Injuries 502 III Abbreviations and Symbols Commonly Used in
BODY ANIMAT3D: Concussions 505 Medical Notations   A-24
SKILLS VIDEO: Controlling Bleeding 505 Glossary  G-1
SKILLS VIDEO: Cleaning Minor Wounds 509 Index  I-1

x CONTENTS

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Procedures
PROCEDURE 1-1 Obtaining Certification/Registration PROCEDURE 12-1* Creating a New Patient Record Using EHR
Information Through the Internet 9 Software 247
PROCEDURE 1-2 Locating Your State’s Legal Scope of PROCEDURE 12-2* Checking in and Rooming a Patient Using an
Practice 10 Electronic Health Record 247
PROCEDURE 3-1 Self-Evaluation of Professional Behaviors 40 PROCEDURE 12-3* Creating an Appointment Matrix for an
PROCEDURE 4-1 Communicating with the Anxious Patient 59 Electronic Scheduling System 248
PROCEDURE 4-2 Communicating with the Angry Patient 59 PROCEDURE 12-4* Scheduling a Patient Appointment Using an
PROCEDURE 4-3 Communicating with the Assistance of an Electronic Scheduler 248
Interpreter 60 PROCEDURE 13-1 Creating a Filing System for Paper Medical
PROCEDURE 5-1 Obtaining Signature for Notice of Privacy Records 265
Practices and Acknowledgment 91 PROCEDURE 13-2 Setting Up an Office Tickler File 266
PROCEDURE 5-2 Completing a Privacy Violation Complaint PROCEDURE 13-3 Developing a Records Retention Program 266
Form 92 PROCEDURE 14-1 Using a Video Relay Service with an American
PROCEDURE 5-3 Obtaining Authorization to Release Health Sign Language Interpreter 287
Information 92 PROCEDURE 14-2 Renewing a Prescription by Telephone 288
PROCEDURE 6-1 Aseptic Handwashing 109 PROCEDURE 14-3 Screening and Routing Telephone Calls 289
PROCEDURE 6-2 Using an Alcohol-Based Hand PROCEDURE 14-4 Handling Emergency Calls 289
Disinfectant 110 PROCEDURE 14-5 Retrieving Messages from an Answering
PROCEDURE 6-3 Using a Biohazardous Sharps Container 110 Service or System 290
PROCEDURE 6-4 Disposing of Biohazardous Waste 110 PROCEDURE 15-1* Creating Electronic Patient Instructions 309
PROCEDURE 7-1 Handling a Fire Emergency 136 PROCEDURE 15-2 Identifying Community Resources 310
PROCEDURE 7-2 Maintaining and Using an Eyewash PROCEDURE 15-3 Locating Credible Patient Education
Station 137 Information on the Internet 310
PROCEDURE 7-3 Creating a Pediatric Reception Area 138 PROCEDURE 15-4 Developing a Patient Education Plan 311
PROCEDURE 7-4 Creating a Reception Area Accessible to PROCEDURE 15-5 Outpatient Surgery Teaching 311
Patients with Special Needs 138 PROCEDURE 16-1 Creating an Appointment Matrix 334
PROCEDURE 7-5 Opening and Closing the Medical Office 139
PROCEDURE 16-2 Scheduling Appointments 334
PROCEDURE 8-1 Using a Facsimile (Fax) Machine 174
PROCEDURE 16-3 Completing the Patient Appointment Card 334
PROCEDURE 8-2 Using a Photocopier Machine 175
PROCEDURE 16-4 Placing Appointment Confirmation Calls 335
PROCEDURE 8-3 Using a Postage Meter 175
PROCEDURE 16-5 Scheduling Outpatient Surgical
PROCEDURE 8-4 Using a Check-Writing Machine 176 Appointments 335
PROCEDURE 8-5 Step-by-Step Overview of Inventory PROCEDURE 16-6 Scheduling Inpatient Surgical
Procedures 176 Appointments 336
PROCEDURE 10-1* Creating a Professional Letter 205 PROCEDURE 17-1 Verifying Workers’ Compensation Coverage 374
PROCEDURE 10-2 Writing an Interoffice Memo 206 PROCEDURE 17-2 Submitting a Request for Prior Authorization 375
PROCEDURE 10-3 Composing a Professional E-mail PROCEDURE 17-3 Completing the CMS-1500 Claim Form 375
Message 206
PROCEDURE 17-4 Tracking Insurance Claims Submissions 377
PROCEDURE 10-4 Composing an Electronic Patient Letter Using a
PROCEDURE 18-1 Locating an ICD-10-CM Code 401
Template 207
PROCEDURE 18-2 Locating a Health Status (Z) Code 402
PROCEDURE 10-5 Sorting and Opening Mail 207
PROCEDURE 18-3 Locating an External Cause Code 402
PROCEDURE 11-1 Preparing a New Patient Paper Medical
Record 231 PROCEDURE 19-1 Locating a CPT Code 424

PROCEDURE 11-2 Correcting Paper Medical Records 231 PROCEDURE 19-2 Locating a HCPCS Code 424
PROCEDURE 11-3 Entering (Adding) Information into a Paper PROCEDURE 19-3* Entering CPT and ICD Codes into an EHR
Medical Record 232 Program 425

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PROCEDURE 20-1 Posting Charges, Payments, and
Adjustments 460
PROCEDURE 20-2 Using the Superbill as Bill/Receipt 460
PROCEDURE 20-3 Posting a Nonsufficient Funds (NSF) Check 461
PROCEDURE 20-4 Processing a Payment Resulting in a Credit
Balance 461
PROCEDURE 20-5 Processing Refunds to Patients 462
PROCEDURE 20-6 Preparing an Age Analysis 462
PROCEDURE 20-7 Referring an Account to a Collection
Agency and Posting the Payment from the
Agency 463
PROCEDURE 20-8 Completing a Truth in Lending Statement
(Agreement) 463
PROCEDURE 20-9 Making a Bank Deposit 464
PROCEDURE 20-10 Reconciling the Bank Statement 465
PROCEDURE 20-11 Setting Up the Disbursements Journal 466
*Indicates EHRClinic video
xii PROCEDURES
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PROCEDURE 56-1 Preparing a Travel Expense Report 493
PROCEDURE 56-2 Preparing an Agenda 493
PROCEDURE 56-3 Completing an Incident Report 494
PROCEDURE 56-4 Generating Payroll 494
PROCEDURE 57-1 Stocking the Crash Cart 520
PROCEDURE 57-2 Performing an Emergency Assessment 521
PROCEDURE 57-3 Foreign Body Airway Obstruction in a
Responsive Adult or Child 521
PROCEDURE 57-4 Foreign Body Airway Obstruction in a
Responsive Infant 523
PROCEDURE 57-5 Controlling Bleeding 524
PROCEDURE 57-6 Cleaning Minor Wounds 524
PROCEDURE 57-7 Caring for a Patient Who Is Vomiting 525
PROCEDURE 57-8 Assisting During a Chemical Disaster 525
PROCEDURE 58-1 Résumé Writing 546
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Digital Exercises and Activities
NEW! EHRclinic Exercises
5.01 Add an Acknowledgement of Receipt of NPP to a
Patient’s EHR 95
5.02 Add an Authorization to Release Health Information
to a Patient’s EHR 95
6.01 Add a Note to a Patient’s EHR 112
8.01 Assign Staff Access Levels in an EHR 180
8.02 Assign a Task Item 180
10.01 Create a Patient Test Result Letter 210
10.02 Create an Excuse Note 210
10.03 E-mail a Patient 210
11.01 Add a New Patient to the EHR 235
11.02 Edit Patient Demographics 235
11.03 Record a Patient’s Vital Signs 235
11.04 Record a SOAP Note 235
12.01 - 12.23 EHR review exercises 265
13.01 Update the Status of the Recall List 269
14.01 Create an Electronic Telephone Encounter 293
14.02 Create an Urgent Electronic Telephone
Encounter 293
14.03 Complete a Prescription Refill Request 293
15.01 Document Administration of Patient Education 314
15.02 Document Administration of ­Pre- and Post-Operative
Instructions 314
16.01 Maintain a Provider’s Schedule Matrix in an EHR 339
16.02 Add a Patient to the Schedule in an EHR 339
16.03 Cancel a Patient’s Appointment in an EHR 339
16.04 Document Administration of Surgical
Instructions 339
17.01 Create and Submit an Insurance Claim 380
18.01 Assign a Diagnostic Code to an Office Visit - A 405
18.02 Assign a Diagnostic Code to an Office Visit - B 405
18.03 Maintain the Diagnosis Code Database in an EHR 405
19.01 Assign a Procedure Code to an Office Visit - A 427
19.02 Assign a Procedure Code to an Office Visit - B 427
19.03 Maintain the Procedure Code Database in an EHR 427
20.01 Record a Patient Payment 469
20.02 Post Insurance Deposits to the Practice Account 469
20.03 Create a Patient Statement 469
20.04 Create an Age Analysis Report 469
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20.05 Handle a Returned NSF Check 469
20.06 Process a Patient Payment 469
20.07 Issue a Patient Refund 469
56.01 Assign Access Rights to an Employee 497
Body Animat3D
Concussions 505
Burns 527
Administrative and
Clinical Skills Videos
Communicating with the Anxious Patient 54
Communicating Effectively with Patients from Other Cultures
and Meeting Their Needs for Privacy 55
Aseptic Hand Hygiene 102
Establishing and Conducting the Supply Inventory and
Receiving Supplies 165
Guidelines for Disinfecting Exam Room
Surfaces 185
Registering a New Patient 214
Initiating a Paper-Based Patient Medical Record 219
Correcting the Patient Medical Record 228
PHI Authorization to Release Health Information 246
Managing a Prescription Refill 279
Scheduling Outpatient Surgical Appointments 330
Scheduling Inpatient Surgical Appointments 331
Requesting Prior Authorization 358
Locating an ICD-10-CM Code 401
Locating a CPT Code 421
Posting Charges, Payments, and Adjustments 444
Petty Cash 476
Completing an Incident Report 484
Performing an Emergency Assessment 502
Controlling Bleeding 505
Cleaning Minor Wounds 509
Caring for a Patient Who Is Vomiting 512
Performing Cardiopulmonary Resuscitation (CPR) 514
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NEW! Application-Based SmartVideo: BPH vs Prostate Cancer

SmartVideo: The Prostate Gland
Activities (ABAs) Including SmartVideo: The Mammary Gland
Practice Medical Office (PMO) SmartVideo: Breast Cancer
Drawing Up an Injection SmartVideo: Breast Cancer Treatment
Obtaining a Pulse Oximetry Reading SmartVideo: Food Absorption
Flu Shot Incident SmartVideo: Blood Pressure & Hypertension
Dealing with an Angry Parent SmartVideo: Hypertension Treatments
Clean Catch Mid- Stream Urine Collection SmartVideo: The Liver – Anatomy and Function
Performing Venipuncture Using an Evacuated System SmartVideo: Liver Failure and Treatment
Harassment in the Clinic SmartVideo: Liver Failure – Acetaminophen Overdose
Holter Monitor SmartVideo: Measuring Aduitory Acuity
Admin Check In: Interactions 43, 63 SmartVideo: Measuring Blood Glucose Using a Handheld
Glucometer
Admin Check In: Office Operations 113, 180, 293
SmartVideo: Measuring Hematocrit Percentage after
Admin Check In: Privacy and Liability 96, 210, 235
Centrifuge
Admin Check In: Work Task Proficiencies 142, 380
SmartVideo: Meiosis
Admin Check Out: Interactions 314 SmartVideo: Mitosis
Admin Check Out: Office Operations 405 SmartVideo: Obtaining Information from a Geriatric Patient
Admin Check Out: Privacy and Liability 252, 497 SmartVideo: Performing Ear Irrigation
Admin Check Out: Work Task Proficiencies 269, 339, 428, SmartVideo: Performing Vision Screening Tests
469, 548
SmartVideo: Preparing a Blood Smear
Clinical: Interactions
Clinical: Office Operations 195 Find the complete list of of NEW! Application-Based
Clinical: Privacy and Liability 528 Activities (ABAs) with the Instructor Resources on
Clinical: Work Task Proficiencies Connect.

xiv D I G I TA L E X E R C I S E S A N D AC T I V I T I E S

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Medical assisting is a rock-solid career with a variety of essen-
tial tasks. These tasks are always expanding and changing as
the healthcare environment changes. Learning these tasks and
stacking them together can be a challenge. The seventh edi-
tion is updated to help students as well as instructors learn
these ever-changing tasks and stay current in the healthcare
environment. McGraw-Hill is committed to helping prepare
students to succeed in their educational program and career
by providing a complete and easy set of solutions for the
educators of these programs. The following will give you
a snapshot of some of the exciting solutions available with
the seventh edition of M­ edical ­Assisting: Administrative and
Clinical Procedures with Anatomy and Physiology for your
Medical Assisting course. Instructors across the country have
told us how much preparation it takes to teach medical assist-
ing. To help, we have added more detailed information on how
to organize and utilize the many available practice features
and activities, as well as a breakdown by Learning Outcomes
for corresponding activities entitled the Comprehensive Asset
Map, located in the Instructor Resources portion of Connect.
The Content—a Note from the Authors
The seventh edition of Medical Assisting: Administrative and
Clinical Procedures with Anatomy and Physiology has many
exciting and noteworthy updates. With insightful feedback
from our users and reviewers, our experienced author team
set out to create a one-of-a-kind, dynamic, practical, realistic,
FIGURE FM-1 The new Practice Atlas.
©McGraw-Hill Education
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A Closer Look
and comprehensive set of tools for individuals preparing to
become medical assistants as well as the instructors helping
them to accomplish this task.
When you begin the book, you will find it is not just
about rote memorization of concepts. Medical Assisting
immerses you in the world of BWW Medical Associates,
where you learn as you confront new workplace challenges in
each chapter. All elements of the book—from the case studies
in each chapter and the Soft Skills Success exercises to the
screenshots and other visuals—immerse the stu-
dent in a realistic learning environment. Case studies are built
around a set of patients who regularly visit BWW Medical
Associates, and you will get to know these patients as well
as the employees of BWW Medical Associates as you move
through the chapters and the accompanying EHR exercises.
Within this framework, we have worked to provide the most
up-to-date information about all aspects of the medical assisting
profession, with a focus on consistency, authenticity, and accu-
racy. Along with thousands of minor tweaks and updates, Medi-
cal Assisting, seventh edition, incorporates the following:
• New! Over 100 electronic health record exer-
cises correlated to 34 chapters.
• New! A complete set of 23 exercises included
with Chapter 12 Electronic Health Records that provides
documentation of EHR proficiency and a “big picture”
journey for the student.
• Dozens of BWW EHR documentation/progress note
examples in both clinical and administrative chapters.
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• Soft Skills Success exercises located with the Chapter
Review that test employability skills and link students to
related modules in Practice Medical Office (PMO) and
Application-Based Activities (ABAs).
• Over 30 screenshots throughout the
text to showcase basic EHR skills in the context of the
BWW Medical Associates.
• Case studies that are enhanced by the inclusion of more
detailed clinical information and link to the new Soft Skills
Success activities where applicable.
• Coding content focusing on ICD-10-CM, including detailed
1500 claim form instructions utilizing the 5010 updates to
make the form compliant with ICD-10 requirements
• New! Thirteen math and dosage videos and questions
located as assignments in Connect.
• Inclusion of content and terminology related to all of the
current medical assisting standards to help ensure student
certification success.
• Brand new level heading in all of the anatomy and physiol-
ogy chapters titled “Diagnostic Exams and Test.”
• New! Medical Terminology Practice feature with the
anatomy and physiology chapters to bring further under-
standing of the power of the construction and deconstruc-
tion of medical terms, as well as corresponding practice
questions in the Chapter Review.
• New! Corresponding practice of anatomy and physiology
with Practice Atlas on Connect.
A more detailed list of chapter changes is covered in the next
section.
Key Chapter-by-Chapter Changes
The following chapter-by-chapter list includes the essential
changes and updates made to the book. A full list of changes
is available in the transition guide provided in the Instructor
Resources on Connect.
Chapter 1 The medical assistant as a patient navigator,
scope of practice procedure, standard of care,
and practice test provided by certification
organizations. A new procedure titled Locate
Your State’s Legal Scope of Practice
Chapter 2 Affordable Care Act and Patient Centered
Medical Care Home, Medical Scribe
Chapter 3 Professional use of personal electronic
devices and social media, customer service
as professionalism, cultural diversity with
co-workers
Chapter 4 Introduction to Behavioral Health Issues,
Substance Abuse, and Gender Identity and
Sexuality and more detail about Roadblocks to
Effective Communication
Chapter 5 POLST, Advance Medical Directive, DNR,
and DNAR
xvi A CLOSER LOOK
boo77045_fm_i-xxviii.indd xvi
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Chapter 6 OPIM, transmission-based precautions, and
OSHA education and training requirements for
ambulatory care
Chapter 7 Computer Vision Syndrome, service dogs and
comfort animals, visual relay services
Chapter 8 Computer networks and encryption, current
software management programs, monitoring of
professional e-mails, computer security
Chapter 10 E-mail etiquette, delivery notification, invoice
versus statement, using “rules” for e-mail
management
Chapter 11 Records release rules, changed the terminology
from chart to health record, SOMR clarified
Chapter 12 Meaningful Use, expanded coverage of shared
data, general guidelines for using an EHR
program, practice management systems,
updated EHR content with new
program
Chapter 13 Retaining files in the office section, filing to
reflect modern office standards, updated EHR
figures
Chapter 14 Communicating with deaf, Uber, Lyft, and cell
phone use
Chapter 15 Electronic media use, defined modeling versus
return demonstration; sample e-newsletter,
patient information form, and physician
information figures added
Chapter 16 Telehealth, electronic scheduler, examples
of wave scheduling and modified wave
scheduling
Chapter 17 Uninsured, precertification, patient-centered
medical homes (PCMH) concept, Medicare
tax and salary requirement updates,
Insurance 1500 claim form with updated
instructions
Chapter 18 Removed comparison of ICD-9 and ICD-10
codes as ICD-10-CM is now only coding
system used in the United States. All ICD-10
coding exercises updated to 2019 edition
Chapter 19 Changed title to Procedural Coding, updated
to 2019 codes throughout
Chapter 20 In-Office Transactions, Payments After the
Patient Visit, and Returned Checks; new terms
added: accounts receivable (A/R), accounts
payable (A/P)
Chapter 56 Updated figures to be more in line with today’s
earnings
Chapter 57 Updated tourniquet usage, changed triage
to prioritization protocols in Caution box:
Planning and Implementing a Preparedness
Plan for Pandemic Illness
Chapter 58 Stressed leaving options open in the
“Professional Objective” section of the résumé
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A Guided Tour
Learning Outcomes, Key Terms, • ABHES (Accrediting Bureau of Health Education Schools)
Competencies and Curriculum
and Textbook Organization
• AAMA (American Association of Medical Assistants)
Every learning outcome in Medical Assisting, seventh edition,
CMA (Certified Medical Assistant) Occupational Analysis
is aligned with a level I heading. McGraw-Hill has made it even
easier for students and instructors to find, learn, and review • AMT (American Medical Technologists) RMA (Regis-
critical information. The chapter organization of the seventh tered Medical Assistant) Task List
edition is organized to promote learning based on what a medi- • AMT (American Medical Technologists) CMAS (Cer-
cal assistant does in practice. The chapters build on one another tified Medical Assistant Specialist) Competencies and
to ensure student understanding of the many tasks they will Examination Specifications
be expected to perform. The chapters can be easily grouped • NHA (National Healthcareer Association) Certified Clini-
together to create larger topics or units for the students to learn. cal Medical Assistant (CCMA)
For ease of understanding, content can be organized asConfirming
follows:
Pages • NHA (National Healthcareer Association) Certified Medi-
• Unit One, Medical Assisting as a Career—Chapters 1 to 5 cal Administrative Assistant (CMAA)
• Unit Two, Safety and the Environment—Chapters 6 to 9 • CMA (AAMA) Certification Examination Content Outline
• Medical Records
Unit Three, Communication—Chapters 10 to 14 11 • NCCT (National Center for Competency Testing) National
Certified Medical Assistant (NCMA) Detailed Test Plan
• and Documentation
Unit Four, Administrative Practices—Chapters 15 to 20
• NAHP (National Association for Health Profession-
• Unit Five, Applied Anatomy and Physiology—Chapters 21
als) Nationally Registered Certified Medical Assistant
to 34
C A S E S T U D Y
for his rescue inhaler in (NRCMA) content outline
Unit Six, Clinical Practices—Chapters 35 to mother 44 has brought him
the last several days. His
• Patient Name DOB
to the appointment, butAllergies • NAHP (National Association for Health Professionals)
PAT I E N T I N F O R M AT I O N

• Unit Seven,
Mohammad
Nassar
Assisting
05/17/2005 NKA with Diagnostics—Chapters 45 to 50
Mohammad Nassar has
asked that she remain Nationally Registered Certified Administrative Health
Unit Eight, Assisting in Therapeutics—Chapters during his51 to 55
in the reception area
• appointment. Assistant (NRCAHA) content outline
Attending She does give you a list
MRN Other Information

• Unit Nine,
Elizabeth H. Medical
00-AA-007 Assisting Practice—Chapters 56 to 58
of Mohammad’s current
asthma medications and • CAHIIM (Commission on Accreditation for Health Infor-
Williams, MD
matics and Information Management Education)
©David Sacks/Getty Images
the previously completed

Key terms are called out at the beginning of each chapter and
new patient documents.
Keep Mohammad Nassar (and his mother) in mind as

arepractice
set andincomesbold to the throughout
office today for an annual the
Mohammad Nassar is a teenage male who is new to the
physicaltext
of theto further promote the mas-
you study this chapter. There will be questions at the end
chapter based on the case study. The information in
• SCANS Correlation
examination. He has a known past medical history of asthma,
terywhich
of has learning
been relatively stableoutcomes.
until recently. He states when
he arrives that he has been experiencing an increasing need
the chapter will help you answer these questions.
Correlations to these are included with the instructor
resources located on Connect (see later pages for informa-
tion about Connect™). In addition, CAAHEP requires that all
L E A R N I N G O U T C O M E S K E Y T E R M S
After completing Chapter 11, you will be able to:
audit review of systems
medical assistants be proficient in the 71 entry-level areas of
11.1 Explain the importance of patient medical
records. CHEDDAR sign competence when they begin medical assisting work. ABHES
requires proficiency in the competences and curriculum con-
11.2 Identify the documents that constitute a patient demographic source-oriented medical
medical record. record (SOMR)
documentation
11.3 Compare SOMR, POMR, SOAP, and CHEDDAR
medical record formats.
noncompliant
subjective
Subjective, Objective, tent at a minimum. The opening pages of each chapter provide
Confirming Pages
a list of the areas of competence that are covered within the
objective Assessment, and Plan
11.4 Recall the six Cs of charting, giving an example of
each. patient record/chart (SOAP)
11.5 Describe the need for neatness, timeliness,
accuracy, and professional tone in patient
problem-oriented medical
record (POMR)
symptom
transcription
chapter.
records.
11.6 Illustrate the correct procedure for correcting and
updating a medical record. M E D I C A L A S S I S T I N G C O M P E T E N C I E S
11.7 Describe the steps in responding to a written CAAHEP ABHES
request for release of medical records.
V.P.1 Use feedback techniques to obtain patient 3. Medical Terminology
information including: d. Define and use medical abbreviations when
(a) reflection appropriate and acceptable
(b) restatement
4. Medical Law and Ethics
Content Correlations V.P.11
(c) clarification
Report relevant information concisely and
accurately
a. Follow documentation guidelines
b. Institute federal and state guidelines when:

Medical Assisting, seventh edition, also provides a correlation VI.C.4 Define types of information contained in the
patient’s medical record
(1) Releasing medical records or information
5. Human Relations
structure that will enhance its usefulness to both students and VI.C.5 Identify methods of organizing the patient’s h. Display effective interpersonal skills with patients
and health care team members
medical record based on:
instructors. We have been careful to ensure that the text and
boo08549_ch11_225-249.indd 225 05/30/19 06:43 PM (a) problem-oriented medical record (POMR)
(b) source-oriented medical record (SOMR)
7. Administrative Procedures
a. Gather and process documents
supplements provide coverage of topics crucial to all of the VI.C.6 Identify equipment and supplies needed for g. Display professionalism through written and
medical records in order to: verbal communications
following: (a) Create
(b) Maintain
(c) Store
• CAAHEP (Commission on Accreditation of Allied Health VI.P.3 Create a patient’s medical record

Education Programs) Standards and Guidelines for Medi- You will also find that each procedure is correlated to the
VI.P.4 Organize a patient’s medical record
X.C.3 Describe the components of the Health
cal Assisting Education Programs ABHES and CAAHEP competencies within the workbook on
Information Portability and Accountability Act
(HIPAA)
X.P.2 Apply HIPAA rules in regards to:
(a) privacy

X.P.3
(b) release of information
Document patient care accurately in the
xvii
medical record
X.A.2 Protect the integrity of the medical record

In this chapter, you will learn how to carefully manage

Introduction
In your career as a medical assistant, a major part of your role
boo77045_fm_i-xxviii.indd xvii will be documenting and maintaining patient health (or medi-
cal) records. These records detail the evaluation, manage-
patient records with the understanding that if the medical care
is not documented, in a legal sense, the medical care did not
occur at all.
10/10/19 07:43 PM
 indicate the days and the hours the practitioner is not schedul-
ing patients
OSHA Guidelines: This procedure does not involve exposure
to blood, body fluids, or tissue.
Materials: Appointment record; pencil or pen; practitioner
schedule of meetings, conferences, vacations, staff meetings,
and other times of unavailability when patients are not seen
Method:
1. Using the practitioner schedule of availability as the base
for the matrix, confer with the practitioner or office
manager to ensure that no additional schedule changes
are planned.
to avoid the need to reschedule appointments.
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2. Indicate within each area the reason the time is being
closed to appointments, such as lunch, hospital rounds,
or a meeting.
RATIONALE: Allows for all users to be aware of provider
location both in and out of the office.
3. If the office utilizes cluster scheduling for certain
appointments such as physical exams and blood sugar
testing, these time frames also must be set apart. Following
office policy, such as using brackets, note the appropriate
appointment type to be scheduled during this time frame.
RATIONALE: It is important for all users to know what type
of appointments can be booked in each time frame.

the procedure sheets. These sheets can be easily pulled out P R O C E D U R E 1 6 - 2 Scheduling Appointments
of the workbook and placed in the student file to document Procedure Goal: Utilizing the previously created matrix, 3. When possible, schedule appointments earlier in the day
proficiency. book patient appointments applying the correct amount of time
for each appointment
first and then move to later time frames. Do ask the
patient if he or she has a preferred time frame in mind
and, if at all possible, accommodate the request.
OSHA Guidelines: This procedure does not involve exposure
RATIONALE: Open appointments later in the day allow

Chapter Features
to blood, body fluids, or tissue.
space for unexpected appointments required at a later time.
Materials: Appointment book and pen or pencil, or electronic 4. When using an appointment book, enter the patient
scheduler (with appropriate matrix) template, outlining time name, phone number, and reason for the appointment
Each chapter opens with material that includes the Case frames for patient appointment types
Method:
in the appropriate space, blocking out additional
blocks of time, if necessary, to accommodate a longer

Study, the learning outcomes, a list of key terms, the ABHES 1. Establish the type of appointment required by the
patient, particularly if this is a new patient or a returning
appointment time.
5. If an electronic scheduler is used, use the search option to

and CAAHEP medical assisting competencies covered in the patient.

RATIONALE: New patients typically require a longer
find the next available appointment for the time frame
required for the appointment. Enter the patient name,

chapter, and an introduction. Since the learning outcomes appointment time than do returning existing patients.
2. If necessary, consult the template for the amount of time
phone number, and reason for the appointment.
6. Repeat the appointment information to the patient, giving

­represent each of the level I headings in the chapter, they serve required for the patient appointment. Keep in mind
the reason for the appointment when scheduling (for
any necessary instructions regarding preparation for the
appointment, such as early arrival for blood tests. Also, this

as the chapter outline. Chapters are organized into topics that

example, if the patient required to be fasting). is a good time to remind patients about any copayments
RATIONALE: Some appointments are best scheduled that will be due at the time of the appointment.
at certain times of the day, depending on patient RATIONALE: Patients respond best when they know what
move from the general to the specific. Updated color photo- preparation and equipment or personnel availability. is expected ahead of time.

graphs, anatomical and technical drawings, tables, charts, and • Points on Practice feature boxes provide guidelines
P R O C E D U R E 1 6 - 3 Completing the Patient
text features help educate the student about various aspects on keeping the medical Appointment office
Card running smoothly and
of medical assisting. The text features include the following: efficiently.
Procedure Goal: To accurately complete a patient appoint- Method:
ment card for the patient’s next visit
• Educating the doesPatient feature1. After
boxes
or electronicfocus onthe ways
appointment to
entering the patient’s appointment in the appointment
• Case Studies are provided at the beginning of all chapters. OSHA Guidelines: This procedure not involve exposure book scheduler, repeat

instruct patients about caring for themselves outside

card, entering thethe
to blood, body fluids, or tissue. date and time to the patient to verify accuracy.

They represent situations similar to those that the medical Materials: Appointment book or electronic scheduler, pen, 2. Complete the patient appointment

medical office.
and appointment card appointment date and time on the card. If the practice

assistant may encounter in daily practice. The case studies 348 CHAPTER 16

include pictures of each of the patients who comeConfirming

to BWW Pages
• Caution: Handle with Care feature boxes cover the pre-
Medical Associates for care (and, where applicable, match- cautions to be taken in certain situations or whenConfirming perform- Pages

ing avatars in the new and ABAs). Students are ing certain tasks.
boo08549_ch16_329-353.indd 348 08/08/19 09:03 PM

encouraged to consider the case study as they read each chap-

Medical Records
ter. Case Study Questions in the end-of-chapter review check 11 CAUTION: HANDLE WITH CARE

and Documentation
students’ understanding and application of chapter content. Maintaining Standards of Cleanliness in the Reception Area
Cleanliness is (and should be) one of a medical office’s hallmarks.
Not only is cleanliness required in the examination and testing
4. Spot-clean areas that become dirty. (Remove scuffmarks.
Clean upholstery stains.)
rooms, it is also expected in the patient reception area. A messy 5. Disinfect areas of the reception area if they have been
Confirming Pages
patient reception area reflects badly on the practice. Patients exposed to body fluids. (Immediately clean and disinfect all
for his rescue inhaler in may think, “If they don’t care about this, what else do they not soiled areas.)
C A S E S T U D Y the last several days. His care about?” Maintaining standards of cleanliness helps ensure 6. Handle items with care. (Take precautions when carrying
mother has brought him that the reception area is presentable and inviting at all times. potentially messy or breakable items. Do not carry too much
Patient Name DOB Allergies to the appointment, but As a medical assistant, you may be involved—along with the at once.)
PAT I E N T I N F O R M AT I O N

Mohammad 05/17/2005 NKA Mohammad Nassar has physician, office manager, and other staff members—in setting
the office’s cleanliness standards. Standards are general guide- After the standards have been established, type and post
O U TNassar
COME KEY POINTS
asked that she remain
lines. In addition to setting standards, you will need to specify the them in a prominent place for the office staff (but not the
in the reception area
tasks required to meet each standard. You also may want to cre- patients) to see. The cleaning activities checklist may be posted,
11.6 Illustrate the correct procedure for correcting and The proper way to make corrections in aduringmedicalhis appointment.
record is to
ate a checklist of the tasks required to meet all of these standards. but the person responsible for cleaning the office also should
updating a medicalMRN
Attending record. Other Information draw a single line through the error so thatShethedoes giveentry
original you a list
The following list outlines standards you may want to con- keep a copy. It is everyone’s duty to keep the office looking
of as
is still legible. Make the correction as close Mohammad’s
possible to thecurrent
Elizabeth H. 00-AA-007 sider. Specific housekeeping tasks for meeting those standards clean and presentable.
asthma medications
original entry, noting the reason for the correction, and initial theand
Williams, MD are included in parentheses. A schedule of specific daily and weekly cleaning activities
correction. Any additions to a medical record
©David Sacks/Getty Images
also shouldcompleted
the previously be made
as soon as the need for the addition is noted, and thedocuments.
reason for also should be posted. Less frequent housekeeping duties,
new patient 1. Keep everything in its place. (Complete a daily visual check
the addition or change should be clearly such as laundering drapes, shampooing the carpet, and clean-
Keep Mohammad Nassar (and documented.
his mother) in mind as for out-of-place items. Return all magazines to racks. Push ing windows and blinds, can be noted in a tickler file so that
Mohammad Nassar is a teenage male who is new to the chairs back into place.)
11.7 Describe
practice the steps
and comes in office
to the responding to aan
today for written
annualrequest
physical In you
orderstudy this chapter.
to release There medical
any confidential will be information,
questions atexpress
the end they will be performed on a regular basis.
for release of medical records. of thepermission
written chapter based onpatient
from the the case
muststudy. The information
be received. Unless it in 2. Dispose of all trash. (Empty trash cans. Pick up trash on the It is always a good idea to have a second staff member
examination. He has a known past medical history of asthma,
is the chaptertowill
impossible help
do so, you should
copies answerbethese
madequestions.
and the originals floor or on furniture.) responsible for periodically working with the medical assis-
which has been relatively stable until recently. He states when
should remain in the office. If originals must be released, a 3. Prevent dust and dirt from accumulating on surfaces. tant on housekeeping responsibilities. That person also may
he arrives that he has been experiencing an increasing need
statement of responsibility should be signed by the receiver and (Wipe or dust furniture, lamps, and artificial plants. Polish be responsible for handling cleaning duties when the medical
should be noted in the patient’s chart. Follow-up should take place doorknobs. Clean mirrors, wall hangings, and pictures.) assistant is away from the office.
until the original records are returned to the office and to the
patient’s record. Only release records that are expressly requested
©David Sacks/Getty Images and authorized by the patient. waste, is waste that can be dangerous to those who handle
L E A R N I N G O U T C O M E S K E Y T E R M S Parking Arrangements
it or to the environment. Infectious waste includes human Although some patients walk to the medical office or take
After completing Chapter 11, you will be able to:
waste, human tissue, and body fluids such as blood and urine. public transportation, the majority of patients will probably
11.1 Explain the importance of patient medical
records.
audit
CHEDDAR
review of systems
sign
• Pathophysiology is featuredtravelinby their
each ofvehicles.
thePatients
It also includes any potentially hazardous waste generated in
personal
the treatment of patients, such as needles, scalpels, cultures of
chapters
who drive to the on
office need a place to park.
11.2 Identify the documents that constitute a patient
C A S E
medical record.
S T U D Y demographic
C R I T I C A L
source-oriented medical
T H Irecord N (SOMR)
K I N G anatomy and physiology. These
human cells, and dressings.
sections
The office can offer eitherprovide
Although infectious waste is not commonly generated in
on-street parking students
or a parking lot
or parking garage. On-street parking requires patients to fend for
with details of the most common diseases and disorders of
documentation the patient reception area, it can happen—for example, when
11.3 Compare SOMR, POMR, SOAP, subjective
Recall Mohammad fromand CHEDDAR
the case study at the physician? What documents should he have brought with
noncompliant a patient vomits or bleeds on the rug or on furniture. If that
medical record formats. Subjective, Objective,
each body system and include information on the causes,
beginning of the chapter. Now that you have him, if available? situation should occur, you must clean up the waste promptly.
objective Assessment, and Plan
11.4 Recall the six Cs of charting,
completed giving
the chapter, an the
answer example of
following 2. Your office uses a SOAP format for medical records. After Remember, infectious waste must be handled in accordance
each. questions regarding his case. patient completes her exam,(SOAP)
record/chart with federal law and following OSHA guidelines. Your office
common signs and symptoms, diagnostic exams and tests,
Dr. Williams explain where each of the
11.5 Describe the 1. As a new
need for patient,
neatness,which documents
timeliness, new documents or
problem-oriented symptom obtained during
pieces of information
medical may choose to purchase commercially prepared hazardous
accuracy, andshould be completed
professional tone inprior to
patient Mohammad’s
record (POMR) exam will be filed using the SOAP format.
transcription waste kits for use in cleaning up spills. After cleaning infec-
records. Mohammad being seen by the treatment, and, where possible, the prevention
tious waste from the patient reception area, deposit it in a
biohazard container. Disinfect the site to eliminate possible
of Pages
Confirming each
disease.
11.6 Illustrate the correct procedure for correcting and
©David Sacks/Getty Images
updating a medical record. contamination of other patients. Refer to the chapter Infection
Control Fundamentals to review OSHA guidelines and stan-
11.7 Describe the steps in responding to a written dard precautions.
request for release of medical records.
©David Sacks/Getty Images Office
PAT H OAccess
P H Y Sfor
I OAll
LOGY LO 7.10 LO 23.11
E X A M P R E P A R A T I O N Q U E S T I O N S
The path patients must take to get from the parking area or
1. (LO 11.1) The process of recording information in a 3. (LO 11.2) Which document serves as the “base” for the Common
street to theDiseases andback
office and then Disorders
out again is called the office
• Procedures give step-by-step instructions on how to per-
patient’s medical record is called
a. Auditing
patient medical record?
a. The registration form
ofaccess.
the Skeletal System
Some offices have easier access than others, but ease
of access is important to your patients, particularly those who
FIGURE 7-13 All patients should have access to ample parking and
easy access to the office.
Arthritis is a general term meaning “joint inflammation.”
form specific administrative or clinical tasks that a medical
b. SOAP
c. CHEDDAR
b. The patient medical history form
c. The physical examination form
are older or differently abled (see Figure 7-13).
Although there are more than 100 types of arthritis, we will dis-
©McGraw-Hill Education/David Moyer, photographer

cuss the two most common types: osteoarthritis and rheuma-

assistant will be required to perform. The procedures are
d. Documentation d. The patient demographic form 130 CHAPTER 7
e. Demographics e. The patient review of systems toid arthritis.
2. (LO 11.1) Which of the following are possible uses for 4. (LO 11.2) Which of the following documents from other
referenced within the content when discussed and found in
patient medical records? sources frequently become part of a patient’s medical
OSTEOARTHRITIS, also known as degenerative joint disease
(DJD), is the most common type of joint disorder, affecting
a. Research record?
their entirety at the end of the chapter. In the workbook, the
boo08549_ch11_225-249.indd 225 05/30/19 06:43 PM nearly everyone to some degree by the age of 70. DJD primarily
b. Quality of care (quality control) a. X-rays, CT scan, and MRI results affects the weight-bearing joints of the hips and knees, and the
c. Patient education b. Lab results from private labs or hospitals boo08549_ch07_114-142.indd 130
cartilage between the bones and the bones themselves begin
05/30/19 05:49 PM

tearable procedure sheets mirror the exact procedures in

d. Quality of care (quality control) and patient education only
e. Research, quality of care (quality control), and patient
c. Hospital discharge summaries
d. Hospital operative notes
to break down. FIGURE 23-14 X-ray image of the Birmingham Hip Resurfacing
prosthesis of the left hip.

the book and allow for easy practice and assessment. Criti-
education e. All of these Causes. Research points to inflammatory processes or ©Total Care Programming, Inc.
metabolic disorders as the etiology of DJD.

cal procedures also can be studied in Clinical or Admin-

248 CHAPTER 11
Signs and Symptoms. These include joint stiffness, aching,
and pain, especially with weather changes. There is often fluid
Causes. RA is an autoimmune disease. The body’s immune
system attacks the synovium (lining) of the joints, triggering
around the joint and grating noises with joint movement. The inflammation.
istrative skills video exercises on Connect, as well as new grating noise is usually caused by bone-on-bone contact. Signs and Symptoms. In this disease, immune system attacks

step-by-step videos of the procedures using the
boo08549_ch11_225-249.indd
xviii
. Diagnostic Exams and Tests. X-rays of the affected joint are
used to determine if osteoarthritis is present. Blood tests are
248 05/30/19 06:43 PM
used to rule out rheumatoid arthritis.
Treatment. Anti-inflammatory drugs, including aspirin and
nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen
A GUIDED TOUR and Feldene®, may be used. Intra-articular steroid injections may
be tried for severe cases. In some cases, a series of injections
of hyaluronic acid–containing medications is used when other
treatments do not work. These injections serve as joint fluid
replacement. Some success has been found with transplanting
harvested cartilage cells from the patient’s healthy knee
cartilage, which are then grown in the lab and reinjected into
the patient’s diseased joint. Surgical scraping of the joint also
may be done to remove deteriorated bone fragments. As a last
resort, joint replacement may be recommended.
Joint replacement prostheses can be metal, plastic, or a
combination of both. The physician can surgically replace part of
cause edema (swelling), tenderness, and warmth in and around
the joints. Tissue becomes granular and thick, eventually
destroying the joint capsule and bone. Scar tissue forms, bones
atrophy, and visible deformities become apparent due to the
bone malalignment and immobility. Patients also have moderate
to severe pain in the affected joints.
Diagnostic Exams and Tests. Magnetic resonance imaging
(MRI) and X-rays in conjunction with blood tests are used to
diagnose RA.
Treatment. Treatment includes anti-inflammatory drugs, exercise,
heat or cold treatments, and cortisone injections. Researchers are
working with genetic techniques to block the immune system
reaction. Low-impact aerobic exercise may be helpful, and some
patients find warm water exercises beneficial, too.
anim
a
D

ti
AT3

boo77045_fm_i-xxviii.indd xviii the joint (partial) or the entire joint (total). An example of a partial 10/10/19 07:43 PM
on

hip replacement is the Birmingham Hip Resurfacing prosthesis.

IM

od
yAN
In this procedure, the head of the femur is replaced by an all- Go to CONNECT to see an animation exercise
 6. (LO 15.4) When checking an Internet site for credibility, ing procedure that would be done?
The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems in healthcare safety and how to which of the following is least likely to be necessary? a. Blood work

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solve them. a. Use caution if the site uses a sensational writing style. b. Colonoscopy
Identify Patients Correctly • Use at least two ways to identify patients. For example, use the patient’s name and date of birth. b. Look for the author of the information you plan to use. c. Chest X-ray
This is done to make sure each patient gets the correct medicine and treatment. c. Check the date of the document you plan to use. d. ECG
• Make sure that the correct patient gets the correct blood when he or she gets a blood transfusion. d. Click links on the site to make sure they are not broken e. Cardiac rehabilitation
Use Medicines Safely • Before a procedure, label medicines that are not labeled—for example, medicines in syringes, and are kept up-to-date.
cups, and basins. Do this in the area where medicines and supplies are set up. e. Ensure that the site is listed on at least two search
• Take extra care with patients who take medicine to thin their blood. engines.
• Record and pass along correct information about a patient’s medicines. Find out what medicines 7. (LO 15.6) Which of the following would least likely be
the patient is taking. Compare those medicines to new medicines given to the patient. Make sure in the patient information packet?
the patient knows which medicines to take at home. Tell the patient it is important to bring an a. Office policies and hours Go to CONNECT to complete the EHRclinic exercises:
up-to-date list of medicines every time he or she visits a doctor. b. Patient instruction sheet regarding common tests done 15.01 Document Administration of Patient Education
at the practice and 15.02 Document Administration of Pre- and
Prevent Infection • Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the
c. Patient instruction sheet about healthy living Post-Operative Instructions.
World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand
Each chapter closes with a summary of the Learning cleaning.
• Use proven guidelines to prevent infection after surgery.
• Soft Skills Success practice scenarios emphasize employ-
d. List of the physicians with their qualifications
e. Patient confidentiality statement

­Outcomes. The summary

Prevent Mistakes in Surgery
is followed by an end-of-chapter
• Make sure the correct surgery is done on the correct patient and at the correct place on the
patient’s body.
ability skills and critical thinking in complex situations.
8. (LO 15.7) What visual tool is especially helpful when
performing preoperative education?

review with questions related to the case study, as well as 10

• Mark the correct place on the patient’s body where the surgery is to be done.
• Pause before the surgery to make sure that a mistake is not being made.
These new exercise features are included in most non-A&P
a. Anatomical model
b. Printed information sheet

multiple-choice exam-style questions.

c. Line drawing
Source: Adapted from The Joint Commission 2017 National Patient Safety Goals from http://www.jointcommission.org, accessed December 26, 2018. chapters and are correlated to Practice Medical Office and
d. Class or seminar
e. Sensory teaching
Application-Based Activities where applicable.
S U M M A R Y O F L E A R N I N G O U T C O M E S
OUTCOME KEY POINTS

2.1 Discuss healthcare trends and their relationship to Medical assistants typically work in ambulatory care settings S O F T S K I L L S S U C C E S S
medical assistant practice. using EHR. They can expect to work with many older patients
and should practice and assist patients with preventive care. A 35-year-old male patient is scheduled for a vasectomy
2.2 Identify medical specialties and specialists certified by The ABMS certifies 24 major medical specialties and tomorrow. It is within your scope of practice to provide
the American Board of Medical Specialties (ABMS). subspecialties. Medical specialties range from cardiology to preoperative instruction, and you feel confident in performing
oncology. As new medical advances occur, a demand for more this task. When you introduce yourself and explain what you
specialty areas may emerge. are going to do, the first words out of the patient’s mouth are, Go to PRACTICE MEDICAL OFFICE and complete
“How do you know what this is all about? I am the one who the module Admin: Check Out - Interactions.
2.3 Recognize the duties of various allied health Medical assistants are members of a healthcare team. The is getting things cut!” How would you respond to this patient?
professionals with whom medical assistants may work. healthcare team includes physicians, nurses, physical therapists,
other allied health professionals, and patients. Understanding
the duties of other healthcare professionals will assist you as
a professional medical assistant. Even if you do not work with
some of the team members directly, you may have to contact

The book also includes a glossary and three appendices

them through telephone, written, or electronic communication.
2.4 Compare specialty careers that a medical assistant A variety of medical specialty careers are available for the
may choose for advancement. practicing administrative or clinical medical assistant. These
careers require additional training or education and/or other
for328 use as reference tools. The glossary lists all the words
CHAPTER 15

2.5 Differentiate professional associations that relate
to healthcare and explain their relationship to the
medical assisting profession.
certifications.
presented as key terms in each chapter, along with a pronun-
Being a member of a professional association is essential to
medical assisting practice. Knowledge of other healthcare and
medical organizations allows the practicing medical assistant to
ciation guide and the definition of each term. The appendi-
boo08549_ch15_308-328.indd 328 05/30/19 05:59 PM

function successfully within his or her profession. ces present a list of common medical terminology, including
prefixes, root words, and suffixes, as well as medical abbre-
viations and symbols. A Diseases and Disorders appendix
26 CHAPTER 2

• Medical Terminology practice exercises have been added provides a quick reference point for patient conditions that the
to all the anatomy and physiology chapters.
boo08549_ch02_012-028.indd 26 05/30/19 05:45 PM
student may encounter.

A GUIDED TOUR xix

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Digital Materials for Medical Assisting
For the seventh edition, we enhanced the integration between
the textbook and our digital study materials and expanded
our offerings to better cover all aspects of medical assisting.
Links between the textbook and the key study resources are
highlighted by eye-catching icons divided by resource type.
Digital study resources with icons include BodyANIMAT3D,
electronic health record exercises, and both Admin-
istrative and Clinical Skills videos. Real-life practice opportu-
nities include Practice Medical Office and Application-Based
Activities, with icons at the end of the chapter.
Go to CONNECT to see a video exercise about
Establishing and Conducting the Supply
Inventory and Receiving Supplies.
These different types of icons are then used to call out
specific activities and exercises by name. For example, above
you can see an icon for Connect skills videos (the resource)
about Establishing and Conducting Supply Inventory and
Receiving Supplies (the exercise name).
McGraw-Hill Connect® Medical Assisting
A number of our key resources for Medical Assisting, 7e—
including BodyANIMAT3D activities, skills video exercises,
and electronic health records exercises—are part of
our Connect offering for Medical Assisting.
Here is more on what you can expect to find in Connect for
Medical Assisting, 7e, specifically:
• NEW! Exercises
∘ Over 101 electronic health record actionable exercises
correlated to over 34 chapters of Booth Medical Assisting,
7th edition. These simulated exercises allow students to
navigate the tool while learning the tasks of a
Medical Assistant.
• NEW! financial practice management exer-
cises designed to provide students with practical experi-
ence with electronic billing, charge capture, payment
posting, and more.
• Pre- and Post-Tests
• End-of-Chapter Exercises
• Interactive Exercises
• Administrative and Clinical Skills Video Exercises*
• BodyANIMAT3D Exercises*
• ICD-10 Coding Exercises*
∘ Utilizing scenarios developed by the authors, students
can practice identifying and inputting the proper ICD-
10 codes.
*in applicable chapters
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• Medical Terminology Practice*
∘ A refresher area for the body systems chapters with
Word Part exercises on select terms as well as audio
terms with associated spelling practice.
• NEW! Math and dosage videos with questions that rein-
force basic math needed by Medical Assistant students.
• NEW! Practice Atlas exercises for all of the Anatomy and
Physiology chapters. The Practice Atlas for Anatomy &
Physiology is an interactive tool that pairs images of com-
mon anatomical models with stunning cadaver photography,
which allows students to practice naming structures on both
models and human bodies. Additional multiple choice ques-
tions for practice are available as assignments in Connect.
• A completely revised and updated Test Bank (also avail-
able through the Instructor Resources).
As part of Connect for Medical Assisting, we also offer Smart-
Book’s adaptive reading experience, which is powered by
LearnSmart, the most widely used adaptive learning resource.
For more information on Connect—the teaching and
learning platform used with all McGraw-Hill Education
products—and SmartBook, look for the section Connect,
Required=Results.
Simulations and Games for Medical Assisting
, McGraw-Hill’s NEW electronic health record
tool, allows for the look and feel of a real electronic health
records system fully integrated with CONNECT.
provides over 101 exercises directly correlated to 34 chapters
of Booth Medical Assisting, 7e, with Chapter 12 Electronic
Health Records being the most robust. These actionable exer-
cises allow students to navigate the tool, provid-
ing practical experience using electronic health records while
they learn the tasks of a medical assistant. These simulated
exercises are assignable in Connect and are autograded.
­Chapter 12 includes 23 exercises that take the student through
the paces of electronic health records, including administra-
tive functions and financial management. Completion of these
exercises in total provides the basis for documenting elec-
tronic health record practical experience and gives the student
“the big picture.”
In Practice Medical Office (PMO), the student takes on
the role of a new medical assistant in a 3D, immersive game
focused on teaching the six key skills important to work-
ing in a medical office—professionalism, soft skills, office
acumen, liability, medical knowledge, and privacy. Prac-
tice Medical Office features 12 engaging and challenging
10/10/19 07:43 PM

FIGURE FM-2 The new
©McGraw-Hill Education
FIGURE FM-3 A new Application-Based Activity (ABA)
©McGraw-Hill Education
modules representing the functional areas of a medical prac-
tice: administrative check-in interactions, clinical interactions,
and administrative check-out interactions. As the players
progress through each module, they will be faced with realis-
tic situations and learning events that will test their mastery of
critical job readiness skills in a fun, engaging learning expe-
rience. The PMO modules will be found together with the
­Application-Based Activities described below.
For a demo of Practice Medical Office, please go to http://
www.mhpractice.com/products/Practice_Medical_Office and
click on “Play the Demo.” An instructor’s manual for PMO, cor-
related to ABHES and CAAHEP standards by learning event, is
available in your Instructor Resources on Connect.
For the NEW Application-Based Activities, or
ABAs, the student is immersed in a brief, microsimulation
D I G I TA L M AT E R I A L S F O R M E D I C A L A S S I S T I N G
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experience, with the ability to practice steps in key Proce-
dures outside a lab and “virtually” with an instructor. Along
with the Procedure ABAs, students will be able to practice
real-life Scenario ABAs that call upon decision making
and application of medical assisting knowledge. Depending
on the ABA, students will be graded on Objectives such as
Clinical Skills, Administrative Skills, Interpersonal Skills,
Communication, and more, all of which are aligned with
ABHES and CAAHEP standards in the instructor materials.
Find a full list of the ABAs, as well as resources for how to
incorporate in your course, in the Instructor Resources on
Connect.
On Connect, both the PMO modules and the ABAs can
be found within the “Add Assignment” menu, under “MH
Practice Activity” (title at publication).
xxi
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FOR INSTRUCTORS

You’re in the driver’s seat.

Want to build your own course? No problem. Prefer to use our
turnkey, prebuilt course? Easy. Want to make changes throughout the
65%
semester? Sure. And you’ll save time with Connect’s auto-grading too. Less Time
Grading

They’ll thank you for it.

Adaptive study resources like SmartBook® 2.0 help
your students be better prepared in less time. You
can transform your class time from dull definitions to
dynamic debates. Find out more about the powerful
personalized learning experience available in
SmartBook 2.0 at www.mheducation.com/highered/
connect/smartbook
Laptop: McGraw-Hill; Woman/dog: George Doyle/Getty Images

Make it simple, Solutions for your

make it affordable. challenges.
Connect makes it easy with seamless A product isn’t a solution. Real
integration using any of the major solutions are affordable, reliable,
Learning Management Systems— and come with training and
Blackboard®, Canvas, and D2L, among ongoing support when you need it
others—to let you organize your course and how you want it. Our Customer
in one convenient location. Give your Experience Group can also help
students access to digital materials at you troubleshoot tech problems—
a discount with our inclusive access although Connect’s 99% uptime
program. Ask your McGraw-Hill means you might not need to call
representative for more information. them. See for yourself at status.
mheducation.com
Padlock: Jobalou/Getty Images Checkmark: Jobalou/Getty Images

boo77045_fm_i-xxviii.indd xxii 10/10/19 07:43 PM

 Rev.Confirming
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FOR STUDENTS

Effective, efficient studying.

Connect helps you be more productive with your study time and get better grades using tools like
SmartBook 2.0, which highlights key concepts and creates a personalized study plan. Connect sets you
up for success, so you walk into class with confidence and walk out with better grades.

Study anytime, anywhere. “I really liked this

Download the free ReadAnywhere app and access your app—it made it easy
online eBook or SmartBook 2.0 assignments when it’s to study when you
convenient, even if you’re offline. And since the app don't have your text-
automatically syncs with your eBook and SmartBook 2.0
assignments in Connect, all of your work is available book in front of you.”
every time you open it. Find out more at
www.mheducation.com/readanywhere - Jordan Cunningham,
Eastern Washington University

No surprises.
The Connect Calendar and Reports tools keep you on track with the
work you need to get done and your assignment scores. Life gets busy;
Connect tools help you keep learning through it all.

Calendar: owattaphotos/Getty Images

Learning for everyone.

McGraw-Hill works directly with Accessibility Services
Departments and faculty to meet the learning needs
of all students. Please contact your Accessibility
Services office and ask them to email
accessibility@mheducation.com, or visit
www.mheducation.com/about/accessibility
for more information.

Top: Jenner Images/Getty Images, Left: Hero Images/Getty Images, Right: Hero Images/Getty Images

boo77045_fm_i-xxviii.indd xxiii 10/10/19 07:43 PM


Additional Supplementary Materials
Student Workbook for Use with
Medical Assisting, 7e–in print and full
color (ISBN: 978-1-260-47702-3)
The Student Workbook provides an opportunity for the student
to review and practice the material and skills presented in the
textbook. The workbook is divided into parts and presented
by chapter; the first part provides the following:
• Vocabulary review exercises, which test knowledge of key
terms in the chapter
• Content review exercises, which test the student’s knowl-
edge of key concepts in the chapter
• Critical thinking exercises, which test the student’s under-
standing of key concepts in the chapter
• Application exercises, which include figures and practice
forms and test mastery of specific skills
• Case studies, which apply the chapter material to real-life
situations or problems
Each section, Clinical and/or Administrative, contains
the appropriate procedures, presented in the order in which
they are shown in the student textbook. These have been
revised for ease of use and include correlations to the ABHES
and CAAHEP competencies mastered with the successful
completion of each procedure. Accompanying Work Product
Documentation (work/doc) provides blank forms for many
of the procedures that require a specific type of document to
complete the procedure. These documentation forms are used
when completing many of the application activities as well
as procedure competencies. Over 100 procedures as well as
multiple application activities in the workbook include cor-
related work docs.
Pocket Guide for Use with Medical
Assisting, 7e (ISBN: 978-1-260-47700-9)
The Pocket Guide is a quick
and handy reference to use
while working as a medical
assistant or during training.
It includes critical proce-
dure steps, bulleted lists, and
brief information all medical
assistants should know. Infor-
mation is sorted by Adminis-
trative, Clinical, Laboratory,
and General content.
Instructor Resources
Medical Assisting also comes
with the instructor resources
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you’ve come to expect, all of which can be found through the
Instructor Resources section in Connect.
• An Instructor’s Manual that contains everything to orga-
nize your course, complete with lecture outlines (with
PowerPoint slide references), discussion points, learning
activities, and case studies. Also included are the answer
keys to the book and workbook.
• Correlation Guides map the standards of many accredi-
tation bureaus, including the Accrediting Bureau of
Health Education Schools (ABHES) Medical A ­ ssisting
competencies and curriculum; the Commission on
Accreditation of Allied Health Education Programs
(CAAHEP) Standards and Guidelines for Medical Assist-
ing Education Programs competencies; American Asso-
ciation of Medical Assistants (AAMA) Occupational
Analysis; the Association of Medical Technologists
(AMT) Registered Medical Assistant (RMA) Certified
Exam Topics; the National Healthcareer Association
(NHA) Medical Assisting Duty/Task List; the National
Association for Health Professionals (NAHP) Nationally
Registered Certified Medical Assistant (NRCMA) and
Nationally Registered Certified Administrative Health
Assistant (NRCAHA) content outlines; the Commission
for Accreditation on Health Informatics and Information
Management Education (CAHIIM); and the Secretary’s
Commission on Achieving Necessary Skills (SCANS)
areas of competence, as well as others.
• PowerPoint Presentations have been fully updated to
include the latest figures and content and to mirror the
design of the book. Teaching notes offer suggestions—in
addition to those in the Instructor’s Manual—to keep your
class running smoothly. We also have taken steps to make
our PowerPoints more accessible, including adding alt tags
for images and tables and ensuring that our slides are orga-
nized to be easily read by screen readers.
• A Comprehensive Asset Map breaks down all of the
resources available through the book and Connect by
chapter and by learning outcome to help you identify
what you want to include in your course and where to
find it.
• New! Challenging Topics Asset Map uses Heat Map data
gathered from LearnSmart to determine the most challeng-
ing topics and Learning Objectives for students and then
gives direction as to what resources and practice activities
are available for those Learning Objectives, allowing the
instructor to focus lectures or group chats on areas most
needed.
• A Transition Guide to help users of earlier editions make
the leap to this new edition, with thorough details outlined
by the authors about changes big and small.
10/10/19 07:43 PM

Test Builder in Connect
Available within Connect, Test Builder is a cloud-based tool
that enables instructors to format tests that can be printed
or administered within a LMS. Test Builder offers a mod-
ern, streamlined interface for easy content configuration that
matches course needs, without requiring a download.
Test Builder allows you to:
• access all test bank content from a particular title.
• easily pinpoint the most relevant content through robust
filtering options.
• manipulate the order of questions or scramble questions
and/or answers.
• pin questions to a specific location within a test.
• determine your preferred treatment of algorithmic questions.
• choose the layout and spacing.
• add instructions and configure default settings.
Test Builder provides a secure interface for better protection
of content and allows for just-in-time updates to flow directly
into assessments.
A D D I T I O N A L S U P P L E M E N TA R Y M AT E R I A L S
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Tegrity: Lectures 24/7
Tegrity in Connect is a tool that makes class time available
24/7 by automatically cap¬turing every lecture. With a simple
one-click start-and-stop process, you capture all computer
screens and corresponding audio in a format that is easy to
search, frame by frame. Students can replay any part of any
class with easy-to-use, browser-based viewing on a PC, Mac,
iPod, or other mobile device.
Educators know that the more students can see, hear, and
experience class resources, the better they learn. In fact, stud-
ies prove it. Tegrity’s unique search feature helps students effi-
ciently find what they need, when they need it, across an entire
semester of class recordings. Help turn your students’ study
time into learning moments immediately supported by your lec-
ture. With Tegrity, you also increase intent listening and class
participation by easing students’ concerns about note-taking.
Using Tegrity in Connect will make it more likely you will see
students’ faces, not the tops of their heads.
Check out the Instructor Resources area on Connect for
additional resources, including an image library, sample syllabi,
printable procedure checklists and work documents, and more!
xxv
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Another random document with
no related content on Scribd:
 — Onko sitten ilkeitäkin?

— Useita, melkeinpä kaikki.

— Tukkipoikienkin joukossa?

— Hyvin usein.

— Silloin lähden. Sano minulle kuitenkin nimesi.

— Nimeni on Sultana.

— Ja minun Spilca. Ja miksi ajattelet, etten ole ilkeä.

— Siksi, että menet aina menojasi välittämättä naisten

huutelemisesta.

»Tämä Sultanan vastaus oli minulle kovin mieleen. En sanonut

enää mitään, työnsin lauttani irti rannasta ja solutin sen virran
vietäväksi, Sultanan hymyillessä minulle.»

*****

»Siitä lähtien en enää ollut entinen mies. Elämäni oli ollut tyyntä:
kuin puu, jonka ainoakaan lehti ei liikahda. Nyt oli tuuli yht'äkkiä
alkanut puhallella. Ja Bistritza muutti tykkänään näköä: näin koko
maailman eräiden kasvojen läpi. Kauneus ei kadottanut rahtuakaan
loistostaan, mutta näköni ei ollut entinen.

»En kärsinyt. En vielä tänä päivänä tiedä, mitä on rakkauden kipu,

joka pitelee sydäntä rautapihdein.

Rakastin Sultanaa, kuten lapsi rakastaa häkkilintuaan, joka on sen

ainoa ajatus. Tuo hento olento, joka jäi yksin uhmaamaan
raakalaista, valloitti minut kokonaan. Hän tiesi, etten ollut ilkeä. Hän
oli uhmannut silmiensä voimalla minun lihasteni voimaa ja oli
voittanut. Minun täytyi ajatella Sultanaa ja vain häntä. Onko
vähänarvoista ajatella rakastamatta ja kärsimättä? Ehkäpä muille,
niille, jotka rakastavat ja kärsivät helposti. Minulle tämä oli uutta. Se
järkytti koko olemustani. Tuskin olin eronnut hänestä, kun jo halusin
nähdä hänet jälleen, ja tämä halu karkoitti kaikki muut, kiusasi
minua, sai minut luopumaan tottumuksistani. En enää herättyäni
laulellut, vaan ajattelin Sultanaa. En enää nähnyt puita, eläimiä ja
taivaanrantaa: näin niiden sijasta Sultanan. Minusta oli aivan
yhdentekevää laskinko myötävirtaan vai nousinko ylämaahan. Koko
tässä avarassa ja kauniissa maailmassa kiinnitti vain yksi paikka
mieltäni: Sultanan kotiseutu. Ja yht'äkkiä alkoi muistini pettää,
jollaista ei koskaan ennen ollut minulle sattunut; aloin unohtaa
tehtäviäni, mikä aiheutti paljon ikävyyksiä minulle ja muille.

»Spilca ei enää ollut vapaa mies. Kului muutamia viikkoja, joiden

aikana minä toivoin, että nuo vilpittömät sinisilmät jättäisivät minut
rauhaan. Niin ei käynyt. Pieni vaalea pää syöpyi yhä
yksityiskohtaisemmin mieleeni. Silloin ajattelin:

— No niin, Spilca, kohtaloaan ei voi paeta. Jonakin päivänä

kohtaa itsekukin tiellään kiven, joka antaa hänen matkalleen toisen
suunnan. Etsikäämme tuo kivi. Sittenpähän näemme, mitä se oikein
tahtoo.

Niinpä loppukesällä, pyhän Marian päivänä, pukeuduin

pyhävaatteisiin ja läksin kävelemään Sultanan pientä kotikylää kohti.
Se oli vuoristokylä, joka kyyrötteli kahden kukkulan lomassa,
vuoristopuron partaalla. Lähistöllä oli satavuotisia kuusikoita. Pienet,
valkoiset asumukset merensinisine ikkunoineen olivat hajallaan siellä
täällä kuin valkeat päivänkakkarat. Vaikka ne olivatkin siistit,
hymyilevät, hiljattain tuoreella kalkkivärillä valkaistut, kertoivat niitten
lahoneet ja sammaltuneet kattohirret maalaiskansan puutteesta.
Tämä ei ihmetyttänyt minua. Elettiin orjuuden ja hädän synkkää
aikakautta, joka vallitsi Turkin yliherruuden loppupuolella. Tiedettiin
vuorten suojaamien seutujen säästyneen jossain määrin
hävitykseltä. Vain mies, joka saattoi olla ilman kanssaihmisten
seuraa, nousta vuorille ja elää karhujen parissa, vältti beilicin [=
verotyö], ruoskaniskut ja raskaat verot.

»Saavuin kylään jumalanpalveluksen aikana. Kaikki asukkaat

olivat kirkossa. Minäkin menin sinne ja rukoilin hyvänä kristittynä,
jollainen olin aina ollut. Se teki minulle hyvää. Pappi ja lukkari lukivat
ja messusivat kumpikin paikaltaan täynnä hartautta ja uskoa
hiiskumattoman hiljaisuuden vallitessa.

»En voinut nähdä kirkossaolijoiden kasvoja, sillä olin pysähtynyt

ovensuuhun. Kun väki alkoi poistua kirkosta, saatoin sensijaan
mukavasti etsiä joukosta kaipaamiani kasvoja. Sultanalla oli
seurassaan vanha, pieni nainen, jonka arvelin olevan hänen äitinsä,
ja hänellä oli yllään vaatimaton valkoinen pusero ja hame sekä
musta, hiukan kirjailtu catrintza. Hänen kulkiessaan ohitseni
kumarsin hänelle hiukan hämilläni. Hän vastasi tervehdykseeni
kohteliaasti ja tyynesti osoittamatta lainkaan hämmästystä tai
mielenliikutusta.

»Muukalaisen ilmestyminen pieneen kylään herättää aina

huomiota. Oli nähty meidän tervehtivän toisiamme. Se riitti antamaan
aihetta kuiskailuihin, silmäyksiin, juoruilemiseen itse Herran huoneen
kynnyksellä. Tämä loukkasi aikeitteni puhtautta ja pakoitti minut
ottamaan varman kannan. Tein ripeän päätöksen mennä pyytämään
Sultanan kättä.»

*****

»Aloin seurata molempia naisia. He poistuivat kylästä, nousivat

rinnettä ja menivät taloon, joka sijaitsi puolitiessä vuoren kupeella.
Tällä matkalla ei kumpikaan heistä ollut katsonut taakseen. Tämä
rehtiys herätti minussa luottamusta. Nousin heidän jälessään ja
koputin ovelle. Sultana tuli avaamaan.

»Hän ei hämmästynyt nähdessään minut, mikä seikka sai minut

hämille. Samoinkuin kaksi kuukautta aikaisemmin Bistritzan rannalla
hän nytkin teki minulle melkein saman kysymyksen:

— Hyvää päivää, Spilca! Mikä tuuli tuo sinut luoksemme? Jos

ajatuksesi ovat rehelliset, käy sisään!

— Rehelliset, Sultana, sen vannon Jumalan edessä: tulen

kysymään sinulta, tahdotko Spilcan puolisoksesi…

»Silloin näin punan leviävän hänen kasvoilleen, kun hän sanoi:

— Käy sisään… Neitosta ei kosita kynnyksellä!

»Sitten hän huusi äänekkäästi vanhukselle:

— Täti! Se on eräs Bistritzan tukkilainen, nimeltä Spilca.

»Täti loi minuun ihmettelevän katseen ja kehoitti istuutumaan.

— Tätini on kuuro, sanoi Sultana, ja alkaa myöskin »tulla jälleen

lapseksi». Hänen kanssaan ei sinun ole helppo puhella. Naisparka
on ollut kauan leskenä. Kolme vuotta sitten hän näki ainoan
poikansa heittävän henkensä tappelussa. Syynä mustasukkaisuus.
Poika oli hänen koko elämänsä, hänen vanhuuden päiviensä ainoa
tuki. Silloin hän möi talonsa ja muutti meidän luoksemme; isäni ja
äitini elivät vielä tuohon aikaan. He kuolivat seuraavana vuonna. Nyt
olemme yksin. Elämme joten kuten kättemme työllä. Kuten näet,
Spilca, ei täällä näytä kovin iloiselta… Eikä se kuitenkaan ole
pahinta.

»En voinut vastata mitään. Hän oli puhunut näistä 'ei kovin
iloisista' asioista melkein hymyillen. Tyttö, joka seisoi edessäni, ei
ollut arka eikä ujo kuten tytöt yleensä, vaan voimakassieluinen ja
onnettomuuksien karaisema. Ja kuitenkin lempeä.

»Silmäys, jonka olin luonut sisään astuessani, riitti todetakseni,

että tätä kotia pidettiin kunnossa. Se ei ollut tuollainen maalaiskoti,
joka, milloin se ei ole suorastaan talli, on niin vihamielisen siisti ja
ankaran järjestyksellinen, että vieraan tulee tukala olla. Isosta
tindasta, missä maalaisperhe viettää koko elämänsä, vei ovi kahteen
kamariin. Leveitä ja korkeita vuoteita, joissa kussakin oli kelta- ja
valkojuovaiset peitot ja niissä leveät, melkein maahan ulottuvat
pitsireunustat. Joka sängyn päänpuolessa kömpelösti maalattu
senduk, joka melkein katosi peittojen, verhojen ja tyynyjen taa.
Kaikkialla vuoteen takaisella seinustalla kirjailtuja tyynyjä, paksuja,
monenvärisin kuvioin somisteltuja mattoja. Lattialla niinikään mattoja,
mutta lajiltaan halvempia. Joka huoneessa iso peili valkoisella
puupöydällä, jota peitti kudonnaltaan vuodepeitteiden kaltainen liina.
Maalattuja puutuoleja. Maalaiselämää esittäviä piirroksia.
Idänpuolisissa nurkissa ikooneja, joiden edessä paloi lamppu.
Ikoonit, taulut ja peilit olivat koristellut pitsireunustaisilla verhoilla,
joihin oli uhrattu paljon työtä ja silkkiä. Ikkunoissa liinaverhot, jotka
olivat melkein yhtä kauniit kuin pöytäliinatkin. Ja kummassakin
huoneessa kuteilla oleva kangas.

»Sultanan kodissa oli kaikkea sitä, mitä tavataan jokaisessa

meikäläisessä maalaiskodissa, johon kurjuus ei ole astunut. Ei sen
enempää. Mutta jokainen esine, koko järjestely kantoi lempeän
käden leimaa, joka oli saanut syntymään kodikkuuden, jollaista
harvoin tapaa maalaiskodeissa, joissa 'siistien' huoneitten somistelu
kylmää vierasta ja herättää hänessä epäviihtyisän tunteen ja pelon,
että hän saa aikaan häiriötä.

»Tunsin viihtymystä kuten muinoin vanhempieni luona, jotka olin

kadottanut, kun vielä olin lapsi. Ja sanoin heti Sultanalle mitä
ajattelin:

— Sultana, täältä puuttuu vain voimakas käsivarsi. Kas tässä se

on, ja kaikki käy hyvin!

Hän katsoi minua tiukasti silmiin, ja hänen katseensa tunkeutui

sisimpääni, mutta minä kestin sen, sillä ajatukseni oli vilpitön.

— Spilca, hän sanoi minulle kirkkaalla äänellä, kaikki

onnettomuutemme eivät ole siinä, mitä kerroin sinulle, ja mikä kuuluu
menneisyyteen. On muutakin. En tahtoisi puhua siitä sinulle. Mitäpä
se hyödyttäisi? Ne, jotka olisivat halunneet naida minut, kuten sinä
nyt, eivät ole päässeet sen pitemmälle, vaikka ovatkin tietäneet sen.
On parasta alistua kohtaloonsa».

»Jäin mietiskelemään: Hyvä Jumala, mistähän on kysymys? Joku

maankiertäjä on varmaankin narrannut tyttöparkaa, nauranut hänelle
ja hylännyt hänet sitten. Ehkäpä hänelle on jäänyt syliin
pienokainenkin! Entä senjälkeen? Minä sanoin:
 — Sultana, älä luule minua niin epäinhimilliseksi. Tiedäthän, että
maailma hyökkää nuoren tytön kimppuun. Minä en ajattele kuten
maailma ajattelee. Jos tuossa on koko syysi, koko murhe, joka estää
muita naimasta sinua, voimme me viettää häitä viikon päästä, jos
vain sinä tahdot sitä, kuten minä».

»Nämä sanat kuullessaan näin hänen suoristautuvan tuolillaan.

Hänen loistavat silmänsä räpyttelivät kiivaasti:

— Spilca, sinun epäilyksesi ovat aiheettomat. En ole syypää

mihinkään eikä minun tarvitse soimata itseäni mistään. Olen nyt
kaksikymmenkaksivuotiaana sama kuin maailmaan tullessani.
Onnettomuus on suurempi kuin jos olettamuksesi olisi tosi, vieläpä
suurempi kuin sekin, että minulla olisi »lehtolapsi».

»Odotin hänen sanovan, mikä tuo onnettomuus oli, mutta hän

pysyi vaiti, kääntämättä minusta avointa katsettaan, joka oli kuulas
kuin elokuun taivas.

»Täti tuli pyytämään meitä aamiaiselle. Sultana otti häntä kädestä

ja huusi hänen korvaansa:

— Täti! Spilca pyytää minua vaimokseen. Mitä sanot siihen?

Kumarainen, valkohapsinen vanhus, jonka kasvoihin isorokko oli

jättänyt pahat jäljet, katseli minua hetken säälien ja vastasi:

— Vahinko!… Poika-parka… Siitä ei tule mitään… Kuka uskaltaisi

astua logofatin tielle?

— Kuka on tuo logofat? kysyin minä. Ja mitä tekemistä hänellä on

tämän asian kanssa?
 »Tämä kysymys nostatti katkeran ilmeen Sultanan kasvoille;
hänen katseensa synkistyi. Hänen valkoinen, tyyni otsansa, jota
kehysti sileästi taapäin kammattu tukka, kävi kalpeaksi, kun hän
sanoi tukahtuneella äänellä:

— Se on logofat Costaki, jonka julmuuksista ja tihutöistä olet ehkä

kuullut puhuttavan. Me, kuten kaikki seudun asukkaat, olemme
riippuvaisia hänestä: hän voi antaa meidän elää tai voi tappaa
meidät, aivan kuten haluaa. Ja neitonen, johon hänen huomionsa
kiintyy, on mennyttä kalua. Hänellä on valittavana joko häpeä tai
perheensä perikato. Kaksi vuotta sitten tuo raakalainen mieltyi
minuun onnettomaan. Senjälkeen ei minulla ole ollut rauhaa. Tähän
saakka olen onnistunut pitämään puoliani. Mutta vaara on minulle
ylivoimainen, sillä tuolla miehellä ei ole sydäntä eikä häpyä. Hän on
meidän herramme. Ennemmin tai myöhemmin on minulla edessäni
valinta. Valintani on tehty. Oli aika, jolloin minussa eli toivo, että
aviopuoliso voisi suojella minua. Kukaan ei uskalla uhmata
hirmuvaltiasta. Minua pidetään pacostena [= maanvaiva, vitsaus]. Ja
niitä vastassa, jotka ovat tulleet kaukaa naidakseen minut ja
viedäkseen minut kotiseudulleen, on toinen este: tätini ei tahdo tulla
mukanani. Kaikki hänen vainajansa ovat haudatut tänne, ja hän
tahtoo painaa päänsä lepoon heidän vierelleen. Spilca, nyt tiedät
kaiken, joskaan et tunne tätä kauheutta yksityiskohtaisesti. Kiitän
sinua hyvistä aikeistasi. Siinä olisi pelastukseni. Mutta kuten tätini jo
sanoi, ei siitä tule mitään. Minä tuottaisin sinulle onnettomuutta. Ja
miksi uhmata häntä, kun kerran sanon, ettei siitä olisi mitään hyötyä?
Minun on varmaankin sovitettava jokin pahatyö? Hyvä, minä sovitan
sen.

*****
 »Salakarit, joita kohtalo siroittelee elämän merelle, pakoittavat
ihmiset puikkelehtimaan pienissä aluksissa varovasti rantoja pitkin.
Spilca, Bistritzan tukkipoika, tunsi karit ja välitti niistä vähät. Ja
mieluummin kuin että olisi uponnut nenäänsä myöten suohon hän
heittäytyi aaltojen vietäväksi.

»Minulle ei ole yhdentekevää, millä tavoin kuolen. Minulla on

siihen nähden mielihaluni. Niinpä siis läksin seuraavana sunnuntai-
iltapäivänä lainkaan epäröimättä uhmaamaan salakaria, jota niin
monet voinicit pelkäsivät.

»Ylpeä moldaulainen hora, oli käynnissä kolmen mustalaisen

pitäessä huolta tahdista. Kolmisenkymmentä neitosta, niiden
joukossa Sultana. Parisenkymmentä nuorukaista. Hikoiltiin hiukan,
sillä aurinko paahtoi, mutta siitä eivät tanssijat huolineet. Pidellen
toisiaan sormenpäistä, joita varmemmaksi vakuudeksi eroittivat
toisistaan kirjaillut nenäliinat (säädyllisyyden vuoksi ja myöskin siksi,
että tahdottiin olla mieliksi vanhemmille, jotka valvoivat heitä), tuo
kaunis piiri syöksyy keskustaa kohti. Eräs voinic huutaa: paikoillaan,
paikoillaan! Pienet jalat ja isot jalat iskevät kuin rakeet tannerta,
karheat kourat heilauttavat pikku kätöset korkealle päiden tasalle ja
jälleen alas polviin saakka, sitten kehä laajenee, jolloin tanssijat
loittonevat toisistaan, niin että käsivarret ojentautuvat suoriksi, ja nyt
tuo ihmisseppel juoksee muutaman askeleen oikealle, sitten jälleen
vasemmalle. Kaikki jalat polkevat paikoillaan, paikoillaan!

»Hengähdetään hiukan ja aletaan uudelleen. Se on romanialainen

»hora». Voidakseen rakastaa sitä on oltava romanialainen ja
maalainen. Se ei ole monimutkainen, mutta eloisa ja värikäs kuin
sateenkaari. Siinä häilähtelevät kaulaliinat, jotka ovat joko keltaiset
tai valkoiset riippuen siitä, millainen on ollut silkkiäismato, jota niin
äidillisellä huolella on hoideltu. Lumivalkeasta liinasta valmistetut liivit
ja hameet. Mustat sametti- tai villaesiliinat. Ja sitten kirjailuja ja
pitsejä, jotka ovat nähneet kyyneleitä ja kuulleet huokauksia. Naurua
ja lauluja ei myöskään ole puuttunut, sillä on hauska vaihtaa
kyyneleet nauruksi.

»Kaunis, vähemmän kaunis tai ruma, 'horan' neitonen on aina

miellyttävä poikien silmissä. He tietävät, että hän on siellä etsiäkseen
itselleen puolisoa, sensijaan kuin he tulevat paremminkin etsimään
naista, harvoin aviovaimoa. Tästä johtuu se suuri tarkkaavaisuus,
jolla tytön äiti seuraa tanssijoiden liikkeitä ja kuiskailuja. Pojat ovat
tietoisia tästä vartioinnista, ja siinä onkin selitys nenäliinalle, joka
eroittaa toisistaan kädet, tyydyttää vanhemmat, ja josta ei ole muuta
hyötyä kuin että se korkeintaan kiihdyttää halua.

»Kirjaillussa zabunissaan, valkoisissa housuissa, päässään

leveälierinen, kolmivärisillä nauhoilla somistettu huopahattu on
nuorukainen ennen kaikkea ylpeä sukupuolestaan. Tämä on kovin
neitosen mieleen, joka ei vähääkään epäile olevansa kaunis.
Viimemainitun varovaiseen ja hiukan harkitsevaan vilpittömyyteen
hän vastaa varomattomalla, selvällä lupauksella, joka ei merkitse
hänelle mitään. Jos se tepsii, sitä parempi. Jollei, niin hän taipuu lain
edessä, astuu ikeeseen, perustaa kodin ja hänestä tulee
järkkymätön tapojen vartia, etenkin silloin, kun hän on nuorten
tyttöjen isä, jotka vuorostaan lähtevät 'horaan' etsimään itselleen
aviomiestä.

»'Horat' vietetään aina carciuman lähettyvillä. Se onkin

luonnollista, sillä siitä saa lämpimän ja silloin on hyvä juoda
lasillinen. Ja juodessa puhutaan siksi, että on jotakin sanottavaa, tai
vain siksi, että tahdotaan reuhata. Vain satavuotisen pähkinäpuun
varjossa istuvat valkohapsiset vanhukset juovat muistoille, puhuvat
ystävyydestä ja seuraavat ikäänkuin kaukaa sen elämän kiihkeää
poljentoa, joka ei enää herätä heidän intohimojaan.

»Näin oli minunkin saapuessani. Tutkivista katseista, joita minuun

luotiin, huomasin, että uutinen Sultanan ja minun kihlautumisestani
oli levinnyt kylään. Antaakseni vahvistuksen tälle huhulle menin
tervehtimään morsiantani ja hänen tätiään, minkä jälkeen menin
yksin päärynäpuiden alla olevan yksinäisen pöydän luo, tilasin okan
viiniä ja seurasin rauhassa tanssia ja kapakan edustalla olevien
juomaveikkojen keskusteluja.

»Olin tarpeeksi etäällä viimemainituista, jotta he saattoivat 'horan'

aiheuttaman melun aikana puhella minusta, samalla kun olin
tarpeeksi lähellä kuullakseni osan heidän pakinastaan. Heidän
puheensa eivät olleet pahansuopia minuun nähden. Jotkut
vakuuttivat: 'hän tulee aivan varmaan', 'hän tietää'. Hän oli logofat
Costaki, minun salakarini, koko seudun kauhu. 'Tulkoon vain!',
ajattelin minä.

»Hän tuli. Hevosen kaviot nostattivat tomupilven ilmaan, ja

humaus kävi läsnäolijoiden joukossa. Sekä juomaveikot että tanssijat
ja soittoniekat kääntyivät huolestuneen näköisinä katsomaan
ratsastajaa, joka 'horaa' lähetessään antoi ratsunsa tanssia. Kaikki
ihailivat eläintä. Minäkin ihailin sitä vilpittömästi. Tuollainen juoksija
olisi ansainnut paremman isännän.

»Tuo pieni, tummaihoinen, vilkasliikkeinen mies heitti ohjat

katkaistun akasian rungolle ja hypähti keskelle nuorten parvea.
Kaikki hatut kohosivat ilmaan tervehdykseksi. Hänet ympäröi heti
joukko suosikkeja, jotka kiiruhtivat ilmoittamaan hänelle minun
läsnäolostani. Silloin käännyin ja katsoin häntä arkailematta päin
naamaa. Tahdoin pelata selvää peliä.

»Laihasäärinen logofat kuunteli hajamielisenä puhujien

sanatulvaa. Aika ajoin hän vilkaisi salaa minuun päin, sitten kuulin
yht'äkkiä karhean äänen sinkauttavan uhkauksen, joka oli tarkoitettu
minulle:

— On paras katkaista koivet kuljeskelevilta muukalaisilta!

»Vastasin tähän suoranaiseen taisteluhaasteeseen menemällä

suoraa päätä tanssipaikalle, missä karkelo oli jälleen käynnissä.
Tartuin Sultanan käteen, jota hänen ystävättärensä piteli, ja aloin
tanssia molempien neitosten välillä. Se oli rehellistä peliä; logofat
sensijaan menetteli vähemmän rehellisesti.

»Kuten tiedetään, ei tanssiin liittyvä poika koskaan saa eroittaa

tanssijan ja hänen tyttönsä kättä. Jollei ole paikkaa kahden tytön
välillä, on hänen asetuttava kahden miehen välille. Tämä sääntö on
ehdoton ja sitä kunnioittavat kaikki, jotka eivät etsi riitaa. Logofat
Costaki näki hyväksi nousta sitä vastaan, aiheuttaen yleistä
hämmästystä. Aivan odottamattani tarttui käsi takaapäin Sultanan
puoliseen ranteeseeni. Käännyin katsomaan taakseni. Piiri pysähtyi.
Mustalaisten soitto lakkasi. Kelmeänä seisoi matelija edessäni
mitellen minua vihaa uhoavin katsein ja sanoi tukahtuneella äänellä:

— Sallitko minun tulla piiriin?

— Pyri muualta!

— Tahdon tulla tästä!

— Jos yrität tästä, niin tuosta saat!

 »Työnnälsin häntä polvellani vatsaan, niin että hän tuupertui
maahan. Voihkaisu, ja urho pyörtyi. Kukaan ei rientänyt hänen
avukseen. Kapakka tyhjeni. Naiset läksivät pakoon. Muuan vanhus
huudahti:

— Onneton juttu!

Huusin mustalaisille:

— Hyvästi ensi sunnuntaihin! Tilaan teidät soittamaan Sultanan ja

minun kihlajaisiini!

»Ja käännyin morsiameni kotia kohti. Eräs lastaan taluttava äiti

teki ristinmerkin ja sanoi:

— Jumala varjelkoon meitä onnettomuudesta! »Koko tuolla viikolla

ei Bistritzalla varmaankaan ollut toista niin onnellista tukkipoikaa kuin
Spilca. Logofat ei ollut näyttäytynyt kylässä. Joka ilta vietin
muutaman tunnin Sultanan luona, ja joka ilta hän erotessamme
sanoi minulle:

— Spilca, en voi uskoa onneen, josta uneksimme… Tuo »roisto»

ei suo sitä meille… Ja luulen, että kirous on ylläni…

»Minä upotin katseeni hänen säteilevien silmiensä kuulaaseen

sineen, suutelin hänen puhdasta otsaansa ja puhuin:

— Rauhoitu, Sultana! Taivutamme tädin muuttamaan kanssamme

kauas täältä, Sutcheavan alueelle, missä kotini on. Siellä elämme
onnellisina.

»Sultana hymyili surumielisesti:

 — Sinä et näy tietävän, mikä valta on vainajilla niihin, jotka ovat
heidät haudanneet… Täti antaisi mieluummin polttaa itsensä elävältä
kuin jättäisi hautausmaansa.

»Kihlajaissunnuntainamme ei kapakanisäntä ikävyyksien pelosta

pannut toimeen 'horaa'. Iltasoiton jälkeen menin mustalaisten
puheille ja pyysin heitä olemaan läsnä päivällisillä, jotka syötiin
läheisimpien tuttujen kesken, senjälkeen kun pappi oli kuuluttanut
meidät. Kylän nuoret ryypiskelivät ja pakinoivat laimeasti. Osa heistä
suhtautui tilanteeseen varovasti, kun taas toiset kuiskailivat minulle
salavihkaa, että 'koko seutu iloitsi läksytyksestä, jonka olin tuolle
'koiralle' antanut'…

— Hän pelkää sinua. Te tukkipojat ja metsänhakkaajat olette

vahvoja, sillä te olette vapaita miehiä, kun me taas elämme orjuuden
ikeen alla. Teidän kova ja villi elämänne suojelee teitä ryöstöltä ja
ruoskalta; meillä on talutusnuora kaulassa. Jos logofat suvaitsee
antaa meille keväisin hehtaarin kylvömaata, saamme olla onnellisia,
jollei, on meidän tehtävä päivätöitä yksinomaan hänelle. Siksi ei
kukaan rohkene nousta häntä vastaan. Kauneimmat neitomme
kulkevat ensin hänen kättensä kautta. Sitten me naimme heidät,
useinpa vielä kohtu siunattuna.

»Illalla, kun noin tusinan verran sukulaisia ja ystäviä, pappi heidän

joukossaan, istui pitkän, häikäisevän valkoisen liinan peittämän
pöydän ympärillä, nousivat heille vedet silmiin avatessani lippaan,
joka sisälsi kihlajaislahjani. Siinä oli beteala [jolla peitetään nuoren
aviovaimon kasvot], kiertäen kuin kultainen vuo jalokivillä koristettuja
korvarenkaita, jotka olin saanut perinnöksi äidiltäni; kaksi
kallisarvoista sormusta; kaksi rubiineilla ja safiireilla somistettua
rannerengasta, ja loppujen lopuksi kuuluisa salba
[talonpoikaisnaisten kaulakoriste], jossa oli kolme suurta leftiä, kaksi
Itävallan keisarillista dukaattia, neljä venetsialaista dukaattia, neljä
polin, kuusi Turkin puntaa ja kymmenen galbenia.

»Kaikki olivat liikutettuja, lukuunottamatta tätiä, joka ajatteli

rakkaita vainajiaan, ja morsiantani, joka ei uskonut onnemme
unelmiin. Valkoisiin puettu Sultana katseli kuin arka kyyhkynen
vuoroon lahjalipasta, vuoroon minun hymyileviä silmiäni. Jokainen
pani parastaan karkoittaakseen hänen synkät aavistelunsa. Pappi
luki hartaan rukouksen ja siunasi avioliittoaikeemme.
Päivällispöydässä laskettiin leikkiä. Mustalaiset soittivat. Kummitäti
kehoitti Sultanaa tuomaan nähtäväksi morsiuskapionsa. Hän teki sen
koneellisesti. Ilakoivat naiset hyökkäsivät sendukien kimppuun:
kauniisti kirjailtuja päivä- ja yöpaitoja, liinoja, tyynynpäällisiä, peittoja,
pyyheliinoja vedettiin esiin ja leviteltiin ympäri huonetta. Sultana
alistui aika ajoin hymyilemään.

»Puoliyön maissa pois lähtiessäni kysyin morsiameltani:

— Sultana, mistä nämä synkät ajatukset?

— Ne eivät ole synkkiä ajatuksia, Spilca; minä tiedän tuottavani

sinulle onnettomuutta. Näen sen tulevan.

»Painoin hänet lujasti rintaani vasten. Hän nojautui minuun täynnä

hellyyttä. Polttava kyynel putosi kädelleni. Sitten tieni peitti
kuusimetsän tuoksu ja lauha elokuinen yö.

*****

Syyskuun loppupuolesta saattoi jo päätellä, että talvi tulisi aikainen

ja ankara, ja eräänä koleana sadepäivänä saavuin kylään, joka
sijaitsi kymmenen kilometrin päässä morsiameni kodista. Paloin
halusta saada nähdä hänet kuusipäiväisen poissaolon jälkeen.
Minulla oli kaikenlaisia ostoksia tehtävänä häitä varten, jotka oli
määrätty vietettäviksi lokakuun ensimmäisenä sunnuntaina.
Kuluneen kuukauden aikana ei Sultanan käytös ollut lainkaan
muuttunut. Kaikissa hänen toimissaan ilmeni varovaisuutta,
vakavuutta, innostuksen puutetta, melkeinpä kylmyyttäkin. Jollen
olisi ollut niin varma hänen vilpittömyydestään, olisin syyttänyt häntä
välinpitämättömyydestä. Mutta olin vakuutettu siitä, että hän kärsi.
Hän ei tahtonut sanallakaan houkutella vanhusta lähtemään
kotiseudultaan. Kaikki minun yritykseni tädin taivuttamiseksi olivat
turhat; hän puhui itsepintaisesti vain vainajistaan. Alistuin tähän siinä
toivossa, että hänen loppunsa ei enää olisi kaukana.

»Seikka, jota pidin ilahduttavana, oli logofatin katoaminen. Sen

päivän jälkeen, jolloin olin potkaissut häntä vatsaan, ei kukaan ollut
häntä nähnyt. Sanottiin hänen olevan sairaana. Jotkut väittivät pelon
pitävän häntä loitolla. Sultana yksin oli vakuutettu siitä, että tuo
'koira' hautoi hirvittävää kostoa.

— Pelkään kaikkea, mutta olen varma vain onnettomuudesta;

tulkoonpa se miltä suunnalta tahansa, tiedän, että se kohtaa meidän
onneamme, ja että sinä kärsit siitä eniten.

»Noiden sanojen jälkeen olin eronnut Sultanasta edellisenä

sunnuntaina. Näkisimme toisemme jälleen vasta seuraavan viikon
lauantaina. Minut pakoitti tähän pitkään eroon suuren tukkilautan
kuljetus Bistritza-joella, sekavien tilien selvittely matkan päätyttyä
sekä eräiden tarpeiden osto, joita oli vaikea saada. Nyt olin matkalla
ylämaahan pitkin jokivartta. Minulla oli nälkä. Olin väsynyt. Kaksi
jättiläismäistä vahakynttilää, jotka kumpikin painoivat kolme okaa ja
joiden oli määrä palaa vihkimistilaisuudessa, rasittivat minua ylen
määrin. Koskaan eivät kantamani hirret olleet niin painaneet
olkapäitäni. On totta, että huoli niiden katkeamisesta oli suurena
tekijänä väsymyksessäni. Vaikka en juuri olekaan taikauskoinen,
alkoi tämä painavuus tuntua minusta epäilyttävältä. Mieleeni muistui
muuan äitini uskomus: vihkiäiskynttilä, joka 'käy painavaksi', on
onnettomuuden merkki; se aviopuolisoista, jonka kynttilä kuluu
eniten juhlamenojen aikana, kuolee ensiksi. Ja niinpä olin valmis
kuuntelemaan ties mitä sisäistä ääntä. Karkoittaakseni mustat
mietteet pysähdyin kylään levähtääkseni, murkinoidakseni, ja
ilahduttaakseni hiukan mieltäni. Ravintolanpitäjä oli tunnettu
hilpeydestään. Kas niin! Helvettiin koko taikauskoisuus!

»Niin juuri, helvettiin! Mutta elämässä käy usein niin, ettei se, mitä
ympärillämme tapahtuu, ole omiaan karkoittamaan taikauskoamme.

»Avaan kapakan oven. Huoneessa on kuusi talonpoikaa ja isäntä.

Kaikki seitsemän lakkaavat keskustelemasta ja käyvät äänettömiksi
huomattuaan minut. Olin kuitenkin ennättänyt kuulla erään heistä
sanovan:

— Poika parka! Hän on surkuteltava!

»Panen pois reppuni ja kynttilät ja kysyn:

— Kuka on surkuteltava?

»Kapakoitsija rientää leikkisänä luokseni:

— Hyvää iltaa, Spilca! Hyvääkö kuuluu?

— Hyvää, Lake, sanon minä, mutta kuka on surkuteltava?

 — Pyh! Paikkakunnalla on sattunut pieni onnettomuus: eräs vaimo
on taittanut säärensä, ja nyt saa mies tehdä vaimonsa työt.

»Minä hymähdän itsekseni. Miksi eivät toiset sano sanaakaan? Ja

miksi he katselevat niin omituisesti pöydälle laskemiani kynttilöitä?

— Mitä katselemista on noissa kynttilöissä? Vihkiäiskynttilöitä!

Luulisipa, ettette ole koskaan ennen sellaisia nähneet!

— Nepä ovat isoja, sanoo joku joukosta, karttaen katsettani.

— Ovathan ne…

— Ehkäpä raskaitakin.

— Hyvin raskaita.

»He eivät sano enää mitään. Koetan niellä hiukan leipää, juoda
tilkan viiniä. Se ei tahdo mennä alas. Nousen ja lähden.

»Ulkona on melkein pimeä. Olen levännyt, mutta kynttilät painavat

jälleen. Vaihdan lakkaamatta käsivartta ilman tulosta. Ja perille on
vielä kaksi peninkulmaa. Tie on yksinäinen ja sateen liottama.
Korvani soivat, vuoroon toinen, vuoroon toinen, mikä on merkki siitä,
että joku puhuu minusta pahaa. Vedän esiin veitseni, avaan sen ja
annan sen riippua oikealla kupeellani. Mutta kuinka väsyttävää
onkaan tähystää kaiken aikaa ympärilleen! Vyöstäni riippuva veitsi
lyö joka askeleella vasten kuvettani. Minusta tuntuu kuin se
syövyttäisi siihen reiän. Taitan veitsen kokoon ja pistän sen jälleen
vyöhöni. Juuri tällä hetkellä ilmestyy kahden askeleen päähän eteeni
pukki, yhtä musta kuin minua ympäröivä yö; se kulkee tien yli ja
katoaa. Ja vaikka hyvin tiedän, että se on pukki kuten muutkin pukit,
oikea pukki, jota sen omistaja etsii kaikkialta, sanon aivan ääneen
itsekseni:

— Se on piru!

»Kohotan oikean käteni tehdäkseni ristinmerkin. Käteni on

lyijynraskas.
Ajattelen:

— Se oli piru! Se estää minua siunaamasta itseäni! Ja nämä

kynttiläthän käyvät niin raskaiksi, etten enää tiedä, miten niitä pidellä!

»Tahdon jälleen avata veitseni, mutta peukaloni on liian heikko

voittamaan jäykkää jousta. Siinä jälleen merkki Pahan läsnäolosta!
Ja yö on niin pimeä, että silmiini koskee.

»Viimein lasken reppuni maahan ja asetan kynttilät tien vierellä

kasvavaa puuta vasten. Silloin huomaan poikenneeni väärälle tielle,
joka kulkee yhdensuuntaisesti oikean tien kanssa. Puut ovat nuoria
poppeleita, suoria ja melkein yhtä paljaita kuin kynttilät. Jälleen
kynttilöitä! Kokonainen kuja! Surkeita kynttilöitä, sammuneita ja
mustia!

— Ei, sanon itsekseni, tämä yö on viimeiseni! En kuole virran

pyörteisiin kuten kuuluisi urhealle tukkipojalle; kuolen pelosta kuin
baba!

»Lopulta onnistun avaamaan veitseni ja tekemään ristinmerkin.

Otan maasta kantamukseni. Ja huomaan rämpiväni upottavalla
pellolla, jonka poikki kuljen päästäkseni oikealle tielle. Yht'äkkiä näen
edessäni kaksi kiiluvaa silmää, jotka tulevat minua kohti. Tunnen
sydämeni pysähtyvän. Reppu ja kynttilät pääsevät käsistäni. Minä
huudan:

— Äiti!

»Bä-ä-ä, kuuluu vastaukseksi. Kiiluvat silmät katoavat.

»Myöhään yöllä pääsen perille loan ja hien peittämänä. Sultanan

asunto on kirkkaasti valaistu, paljon kynttilöitä on sytytetty palamaan.
Kaukaa näen tindan, joka on täynnä ihmisiä.

— Siinä se, sanon minä, täti on kuollut! Nyt tiedän, miksi kohtasin
kaikki nuo onnettomuuden merkit tielläni!

»Mutta enpä tietänytkään, sillä vanhus seisoi isossa huoneessa ja

hypisteli kyynelettömin silmin morsiameni pukua, morsiameni, joka
makasi valkoisen liinan peittämällä pöydällä täydessä hääasussa,
kauniimpana kuin koskaan ennen, kynttilöiden häilähtelevien liekkien
valaistessa hänen vahankalpeita kasvojaan, joihin kuolema oli lyönyt
leimansa. Pitkät, vaaleat silmäripset eivät enää koskaan liikahtelisi.
En enää koskaan saisi nähdä noita kirkkaita ja avoimia silmiä.
Sitruunapuun lehvästä kierretty seppele kaartoi hänen kalpeaa
otsaansa, jolle olin luullut seuraavana sunnuntaina saavani alttarin
edessä painaa pyhän suudelman. Valtoimet, kahtaalle jaetut hiukset
valuivat pitkin hänen jäykistynyttä ruumistaan, sekaantuen betealan
kultalankoihin. Rinnalla lepäävien käsien välissä oli nenäliina, johon
oli kääritty rahat, jotka portinvartijat vaativat kuolleilta avatessaan
heille oven toiseen maailmaan. Ylinnä käärinliina.

»Ja minä, Spilca, jään seisomaan kynnykselle ja katselemaan tätä

kaikkea kuten muutkin.»