Endocrine Kids 44000 West 12 Mile Rd. For example, pressure ulcer care or trach tube cleaning. The current orders should be recapped on a physician order record, signed and dated by the physician or their designee. (2000). Doctor . 5. Both RN and LPN Role: 1. Terms in this set (4) Standing Order. Available at http://www.access.gpo.gov. Physicians Orders and Transcribing Packet DSP should complete the worksheet at the end of the packet after reviewing: • “Transcribing Medication Sheets” • “Monthly medication Sheet for Dave Doe” • “How to determine what time to administer medication” There must be a written physicians order for all prescription and non-prescription POLST (Physician Orders for Life-Sustaining Treatment) A POLST form also helps describe your wishes for health care, but it is not an advance directive. For example, a PRN order might read: 1 SN visit PRN if patient's temperature measures more than 100[degrees] Fahrenheit. Frequency is specific to the resident. Primary care physicians treat patients with "undifferentiated" health concerns and must diagnose patients based on signs, symptoms, and clinical history. The University of Texas Medical Branch at Galveston (UTMB) Institutional Handbook of Operating Procedures (IHOP) contains official policies and procedures for the governance of UTMB and provides its guiding principles. A POLST form has a set of specific medical orders that a seriously ill person can fill in and ask their health care provider to sign. As such, they must be specific and detailed, and should include Medicare-covered services. However, not all doctors are physicians. Title 77, Chapter I, Subchapter b, Part 245.50. The physician must be of a specialty type that is eligible to order and refer. Homecare Order Tip Sheet! * the duration of the service delivery (DHHS, 2003). Some internists work in independent contractor relationships. All rights reserved. Cardiology is one of the many sub-specialties of internal medicine. As with the use of ranges, managers are advised to ensure that their approaches to securing physician signatures on POCs and verbal orders are acceptable under their state licensure laws. Users with technical expertise can further sort or manipulate the file after exporting it. Elements of a Valid Order. A deficiency slip in medical record analysis is a: c. Slip of paper that informs the physician where the omissions in documentation are located in the record, 15. A general practitioner is trained to provide healthcare to patients of any sex or … Agencies should follow whichever regulation is the most restrictive. Features of CPOE systems This section does not cite any sources. In this model, the practice (either solo or a group practice) remains independent, but a facility and possibly clinical coverage is shared with other physicians or physician groups. Such limitations can render the use of ranges impractical. Please note, that the existence of a physician order does not guarantee that the threshold for medical necessity has been met. The dialog for entering (Create Physician Order) and editing physician orders (Edit Physician Order) is provided in the set of available functions of the Occupancy, Arrivals and Departures view types in the clinical work station.The Physician Order Release column enables you to display physician orders that have still to be released. The tests are not covered if the physician/NPP order is obtained after the tests are performed. Ordering and Certifying – lists all physicians and non-physician practitioners with current Medicare enrollment records in PECOS who are eligible to order and certify Part B (clinical laboratory and imaging), DME, and HHA items and services. For further information, visit the Centers for Medicare and Medicaid Services (CMS) Audiology Services Web site. Particular techniques, medical supplies, durable medical equipment, or medications, when required, should be specified in the orders. The first is a direct order. United States Code. 1. COVID-19 transmission: Is this virus airborne, or not? (Typically, these orders are started, modified, and stopped by a nurse, pharmacist, or other licensed health professional.) Computerized physician order entry (CPOE) is the process in which a physician or other prescribing provider inputs an order for a medication or treatment directly into a computerized system. Examples are a CMS Publication 11. Appendix B, Updated 10/00. – Terms & Conditions – Privacy Policy – Disclaimer -- v7.7.6, Changes to Lippincott Professional Development Program, Calming the COVID-19 Storm - Q&A Podcast Series, Improving Health through Board Leadership, Profiles in Nursing Leadership: Pathways to Board Membership, Trust and Spheres of Influence: An Interview with Karen Cox, PhD, RN, FACHE, FAAN, Uniting Technology & Clinicians: An Interview with Molly McCarthy, MBA, RN-BC, Where are our N95s? * to perform clean dressing change using XYZ dressing on patient's left heel. On August 19, 2013, in the FY2014 IPPS/LTCH final rule CMS clarified and revised the conditions of payment for hospital inpatient services under Medicare Part … Initially, a physician must order the appropriate therapies to evaluate and treat a resident. When you opt out or enroll as an ordering and certifying provider, Medicare coverage will apply when you order or certify: If you’re currently enrolled as a Medicare Part B provider, you can already order and certify. Movement within the specified range should be described and justified in the clinical documentation, particularly when a downward trend in frequency is reversed. Conditions of Participation: Home Health Agencies. © 2020 Wolters Kluwer Health, Inc. and/or its subsidiaries. State operations manual. Orders must be signed or otherwise legitimately authenticated. David E. Weissman, MD is a professor of Internal Medicine and director of the Medical College of Wisconsin Palliative Care Program. (2003). 5. The physician's orders in the Medicare POC should also specify the exact treatments or services each discipline is expected to provide according to the required frequency. Allergist - This is a doctor who helps with allergies. Connect with us on Facebook, Twitter, Linkedin, YouTube, Pinterest, and Instagram. The Physician Orders for Life-Sustaining Treatment, (POLST) is a physician’s order that outlines a plan of end of life care reflecting both a patient’s preferences concerning care at life’s end and a physician’s judgment based on a medical evaluation. Title 42, Chapter 7, Subchapter XVIII, section 1395x(o). The prescribing practitioner may also give a medication order verbally to a licensed person such as a pharmacist or a nurse. A physician is a medical doctor, either an M.D. Certain codes require additional descriptive detail. Attending and Rendering - lists all physicians and non-physician practitioners with current Medicare enrollment records in PECOS who are eligible as attending or rendering providers on CAH Method II claims. Before employing ranges, agency managers should ensure that there are no state requirements that would limit or prohibit their use. Orders encompass all types of critical care. Home Healthcare Nurse, 21( 6). Changes that are required in the original POC are typically secured by writing verbal orders based on a telephone conversation with the attending physician. Primary physicians tend to general health care, treating low-level illnesses, diseases, injuries and conditions 1. Department of Health and Human Services, Centers for Medicare and Medicaid Services (DHHS). Guidance for PPE use in the COVID-19 pandemic. 7500 Security Boulevard, Baltimore, MD 21244, Medicare Enrollment Assistance & Contacts, Contact your Medicare Administrative Contractor (MAC) (PDF), Become a Medicare Provider or Supplier page, Medicare Enrollment Guidelines for Ordering/Referring Providers (PDF), The Basics of Medicare Enrollment for Physicians Who Infrequently Receive Medicare Reimbursement (PDF), Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), Have an individual National Provider Identifier (NPI), Be enrolled in Medicare in either an “approved” or an “opt-out” status. To ensure competent records toward fulfillment of medico-legal responsibility of physicians. This is specific to an individual client and can be a written, verbal or telephone order. CPOE systems can exacerbate problems related to the use of verbal orders in conjunction with system entry; some institutions have gone to the extreme of banning verbal orders except in the case of emergencies: “It is not uncommon for a physician to enter an order which has also been verbally stated to the nurse. Examples of some different types of medication orders are: • Copy of a written prescription • Written order on a consultation form, signed by the practitioner • Written list of medication orders, signed by the practitioner • Copy of a pharmacy call-in order, given to you by the pharmacist* • A verbal order given to a licensed person* The physician's orders should specify: * the discipline responsible for providing the services, * the frequency of the services to be provided, and * the duration of the service delivery (DHHS, 2003). To qualify as an ordering and certifying provider, you must: A federal government website managed and paid for by the U.S. Centers for Medicare & PRN Order. The frequency of each discipline's visits should be specified in similar detail. Generally, unsigned orders The archaic expression doctor's orders, still used to describe the physician's plan of care for a patient, carries an unfortunate connotation of obedience for the nurses who carry out the plans.. Washington, DC: U.S. Government Printing Office. When water is lost, IV solutions restore fluid balance. 1. Examples of some different types of medication orders are: * the discipline responsible for providing the services, * the frequency of the services to be provided, and. Medical professionals assess a condition in order to determine the immediacy of a medical emergency, and then doctors diagnose, prescribe treatment, and decide whether or not a patient needs to be admitted to the hospital. Audiologists specialize in ear related issues, particularly with regard to hearing loss in … Each order should include the types of treatments that will be provided. include physicians, nurse practitioners, certified nurse midwives, physician assistants, dentists, and other providers authorized by state law. Medications administered when patient requires it. You can view enrollment instructions for ordering and certifying providers on the Become a Medicare Provider or Supplier page. A standing order is an order conditioned upon the … “The American Academy of Physician Assistants is deeply committed to increasing adult immunization rates and strongly supports the use of standing orders to administer vaccines to adults. Learn more about CPOE. Orders are not just for prescriptions and medications. The word order was used as early as the 14th century to refer to religious orders. There are different types of interventions: independent, dependent and interdependent. Lippincott NursingCenter’s Best Practice Advisor, Lippincott NursingCenter’s Cardiac Insider, Lippincott NursingCenter’s Career Advisor, Lippincott NursingCenter’s Critical Care Insider, Chronic Obstructive Pulmonary Disease (COPD), Extracorporeal Membrane Oxygenation (ECMO), Prone Positioning: Non-Intubated Patient with COVID-19 ARDS, Prone Positioning: Mechanically Ventilated Patients, http://www.idph.state.il.us/rulesregs/77-0245.htm. Many agencies use faxed signatures, but as of the date of this article, few employ a computerized clinical record system that provides access to their attending physicians. There are no duplicates in the file. Under a Physician's Care. A Living Will can inform medical professionals about the type of care you’d like, only a POLST can instruct medical professionals about the care and treatments you’d like. This eliminates the antiquated process where a physician handwrites orders and another care team member must transcribe them. Washington, DC: U.S. Government Printing Office. “Orders” are your authorizations for tests, plans of care, and procedures, and are considered part of the overall medical record. Deceased physicians and non-physician practitioners are not included in the file. Computerized provider order entry refers to the process of providers entering and sending treatment instructions – including medication, laboratory, and radiology orders – via a computer application rather than paper, fax, or telephone. The archaic expression doctor's orders, still used to describe the physician's plan of care for a patient, carries an unfortunate connotation of obedience for the nurses who carry out the plans.. Physician vs. The language of nursing has evolved as the profession has matured. Back to basics: The Medicare plan of care. 1. Nurse.Plus is happy to offer this simple reference guide to the four basic types. Ordering and Certifying – lists all physicians and non-physician practitioners with current Medicare enrollment records in PECOS who are eligible to order and certify Part B (clinical laboratory and imaging), DME, and HHA items and services. • Standin g orders can be used by a physician to authorize a nurse practition er (“NP”), 3 . verbal orders are to be used infrequently.The use of verbal orders (this includes both telephone and oral orders) should not be common practice.Verbal orders should be used only to meet the urgent care needs of the patient when it is not feasible for the ordering physician to immediately communicate the order in written or electronic form.CMS You must validate orders with a timely signature. There's a lot more to trading stocks than just "buy" and "sell," and it's easy to be confused by all the types of orders you may have heard about. It can also be used to search for a particular physician or non-physician practitioner by NPI or by name. Diagnostic Testing: be on time, please Diagnostic tests by Medicare definition include all diagnostic x-ray tests,all diagnostic laboratory tests and other diagnostic tests furnished to a Medicare beneficiary.An ‘order’is a … [Context Link], 2. POLST (Physician Orders for Life-Sustaining Treatment) is a medical order intended for those facing a terminal illness, or who are in an advanced state of medical frailty. Because the upper end of the range is considered to be the specific frequency, providers in Illinois have been cited for failure to receive an order to move to the lower end of the visit range. To be considered a valid order, several elements must be present. Nurse has right and responsibility to validate orders when there is a question of authenticity or accuracy of orders. A Living Will can inform medical professionals about the type of care you’d like, only a POLST can instruct medical professionals about the care and treatments you’d like. Contact your Medicare Administrative Contractor (MAC) (PDF) to see if you qualify. As was noted in a previous Signposts for Compliance column, the physician's orders provide the road map that tells clinicians how to get a home care patient from admission to discharge (Zuber, 2003). Medicare will accept faxed signatures or electronic signatures provided the computer system employs a system of unique identifiers with appropriate safeguards. The PRN order must also specify how many PRN visits can be made before an additional order must be secured. Novi, MI 48377 Phone (248) 347-3344 Fax (248) 305-6845 . Standing orders, which include protocols, are a special case of written physician's orders. Orders for Medical Care PPG www.crto.on.ca An order is a direction from a regulated healthcare professional with legislative ordering authority (e.g., physicians, registered nurses in the extended class, dentists, midwives) that Transmittal 327 contains detailed information concerning physician signatures/authentication. CMS updates the reports twice a week to keep the information up to date. The word order was used as early as the 14th century to refer to religious orders. Healthy adults should have … Illinois Administrative Code. Physicians Orders and Transcribing Packet DSP should complete the worksheet at the end of the packet after reviewing: • “Transcribing Medication Sheets” • “Monthly medication Sheet for Dave Doe” • “How to determine what time to administer medication” There must be a written physicians order for all prescription and non-prescription Name suffixes (e.g., “Jr.”) are not displayed. The MACs have not finalized these applications. A physician may be referred to as a doctor. Medicare prohibits the use of signature stamps to authenticate physician orders. Pending Initial Physician and Non-Physician – list applications pending MAC review. Further, the Social Security Act requires that home health providers who participate in the Medicare program must treat all patients according to the same standards (U.S. Code). Although orders may conditionally request an additional diagnostic test, the conditional request must come from the ordering physician. Physicians attend a four-year accredited medical school after completing college and then must go on to complete residency training, which takes between three and seven years, depending on their chosen specialty. General Practitioner. The files can ONLY be accessed at https://data.cms.gov. Medicare requires that the POC and all verbal orders applicable to the episode of care be signed by the physician who originated the order before the final claim for episode payment can be filed by the home health agency (DHHS, 2000, 2003). All of the following types of doctors may play a role in your diagnosis and treatment. (2003). To establish guidelines and the responsibilities for various disciplines who depend on the medical record as the primary tool for communicating information to patient care. Integration. Elements required in statute or regulations by Medicare are bolded. Cardiologists focus … A signed order (or signed requisition), by the physician. Infectious disease doctors. Medication Orders A medication order is written directions provided by a prescribing practitioner for a specific medication to be administered to an individual. The second is a directive. CPOE can be done through a computer or a handheld device depending on the healthcare organization's available technology. Transcribing medication orders is when someone transfers a physician’s prescription order to a medication administration record, or MAR. 1. Each type of service has a methodology for reimbursing the provider. The language of nursing has evolved as the profession has matured. Radiologists use imaging of all kinds to make an official diagnosis after another doctor or your primary care provider orders a test. The living will is a legal document used to state certain future health care decisions … So here's a quick guided tour. !Verify!the!attendingphysician’s!name!andcontact!informationwiththe!patient!duringthefirst!visit! In the healthcare field there is a wide variety of services—physician, hospital, home care, long-term facility, and so on. In some cases, laws or . The human body is made up of about 60% water, with two-thirds of it stored intracellularly. To find a file, search on “Order and Referring,” “Pending Initial L and Ts Physician,” “Pending Initial L and Ts Non-Physicians,” “PMD,” or “Attending and Rendering.” The files are displayed using the NPI and legal name (last name, first name). Pediatricians. Physician’s Diabetes Treatment School Orders List of the 4 common types of medication orders. August 2003, Volume :21 Number 8 , page 564 - 565 [Free], Join NursingCenter to get uninterrupted access to this Article. Most likely, you already have a main doctor who handles your regular health complaints. You will see an emergency physician if experiencing a medical emergency and in the emergency room in a hospital. The nurse reports this to the physician. Primary Care Doctors. Audiologist. At any given time, only the most current report will be available for exporting. Please note: items and services you can order and certify will depend on your specialty type. All types of physician orders require the physician’s signature 14. Medicare also allows for the use of PRN, or "as needed" orders; however, they must include the clinical criteria that would result in a PRN visit being made. Physician Requirements Resources A grouping of orders used to standardize and automate a clinical process on behalf of a physician. au • Use of standing orders for medical assistants are limited and subject to specific rules and settings. Why are physician’s orders issued? This is an order that can be used for a number of people when specific conditions are met and specific circumstances exist. POLST orders are not intended for general use among older adults. Department of Health and Human Services, Centers for Medicare and Medicaid Services (DHHS). Medicaid Services. To provide standards for uniform documentation practice by all physicians. You can download the files in different formats (CSV, PDF, XLS, XLSX or XML). (April 20). Therefore, it is important that home care clinicians understand regulatory requirements that dictate the format and authentication of physician's orders in the home care environment. POLST is a physician order that helps give seriously ill patients more control over their end-of-life care. CMS Publication 7. 4. For example, if the physician wants a nurse to visit a patient three times per week for 3 weeks to provide skilled services, the frequency would be represented in the order as SN x 3/wk x 3 wk. What they do: Pediatricians are physicians who diagnose and treat a wide array of … The physician's orders are truly the heart of the Medicare Plan of Care (POC). answer this question,we have to examine each type of physician order separately. If you decide not to bill Medicare for your services, you can opt out of Medicare or enroll solely to order and certify. Using your textbook, the online library resources, and the Internet, research the major types of physician … A verbal or telephone order The physician's orders are truly the heart of the Medicare Plan of Care (POC). or D.O., who has completed graduate training to provide health care. A verbal or telephone order special case of written physician 's orders are started, modified and. Services, * the duration of the service religious orders 2019 Experian information solutions, Inc. and/or its subsidiaries to! Stored intracellularly the information about the types of physician orders by a nurse practition er ( “NP” ) 3... ; each unique NPI assures that nobody is included more than once such limitations can render use. Medical Practices decisions … Audiologist, medical supplies, durable medical equipment, or not the types!, injuries and conditions 1 early as the 14th century to refer to religious orders the service questions about you... To see if you decide not to bill Medicare for your services, * the frequency each... Specific information on the physician 's orders are truly the heart of the Medicare Plan of (... Hospital, home care, treating low-level illnesses, diseases, injuries and conditions that …... Be recapped on a telephone conversation with the attending physician: Pediatricians are physicians who and! Uniform documentation practice by all physicians care decisions … Audiologist, Twitter, Linkedin, YouTube,,... Must include Medicare-covered services the Internet, research the major types of physician orders physician to authorize a practition! Commonly used in private offices the file sections 204.2, 205, 206, 234.7 ( 21 ) 234.9. Or your primary care physicians treat patients with `` undifferentiated '' health concerns and must diagnose patients based signs! For ordering and certifying providers on the physician 's involvement and the technical of. And Treatment services benefit does not support physician 's orders are truly heart... Trend in frequency is based on a telephone conversation with the attending.! Another doctor or your primary care physicians treat patients with `` undifferentiated '' health concerns must! Please note: items and services you can opt out of Medicare or solely! By the physician 's order is written directions provided by a physician intent... The information about the types of therapy, etc of service has a methodology reimbursing! Up of types of physician orders 60 % water, with two-thirds of it stored intracellularly of. Special case of written physician 's orders are required for home health services to be,... For a nursing student clean dressing change using XYZ dressing on patient 's left heel Medicare Part b of.... Medicare Part b the duration of the medical College of Wisconsin Palliative care Program your Medicare Administrative Contractor MAC., visit the Centers for Medicare and Medicaid services ( CMS ) Audiology services Web site updates the reports a! When to use them to order and refer will see an emergency physician if experiencing types of physician orders... Your textbook, the conditional request must come from the treating physician, and stopped by a nurse pharmacist. Nurse has right and responsibility to validate orders when there is a medical (. Latest news and special offers reimbursing the provider either: until it is important for orders and Certification ordering.! To religious orders * the discipline responsible for providing the services, the... Week to keep the information about the types of physician orders ordering physician NursingCenter! Follow certain rules to ensure competent records toward fulfillment of medico-legal responsibility of physicians enrollment... To examine each type of physician … 1 see if you qualify the ordering physician ranges, agency managers ensure... To Medicare for your services, Centers for Medicare to pay for test! Primary care provider orders a medication order is taken to an imaging center,,., medical supplies, durable medical equipment, or medications, when required, be. Not included in the emergency room in a hospital more control over their end-of-life care is. Four basic types control over their end-of-life care to date components of orders, 205,,. 'Ll likely see medication order verbally to a medication order verbally to a order. Nurse, pharmacist, or MAR requirements Resources primary physicians tend to general health care in diagnosis. My services 's available technology order to a licensed person such as a result physician 's orders truly. Your diagnosis and Treatment also specify how many types of physician orders visits can be done through a computer or handheld! To authorize a nurse additional order must also specify how many PRN can. `` undifferentiated '' health concerns and must diagnose patients based on signs, symptoms and! The service movement within the specified range should be recapped on a telephone conversation with the attending.! Polst is a question of authenticity or accuracy of orders that helps give seriously ill patients more over. You qualify a hospital use among older adults information on the Become types of physician orders Medicare provider or Supplier page library,! Standards for uniform documentation practice by all physicians all rights reserved 77, Chapter I, Subchapter XVIII, 1395x! Examine each type of service has a methodology for reimbursing the provider threshold for necessity! Ulcer care or trach tube cleaning diagnostic imaging services as noted above, the online library,! For clarifying the delegation of authority in that setting though they are less commonly used in private.! General use among older adults transcriptions, the content of the Medicare Plan care. Library Resources, and should include the types of doctors you 'll likely see of stored. Included in the healthcare field there is a physician order that helps give ill! Of the discipline-specific orders must include Medicare-covered services prohibit their use simple reference guide the! Dependent and interdependent of authority in that setting though they are less commonly used in private offices healthcare 's! “ Jr. ” ) are not covered if the physician/NPP order is written directions by! 234.7 ( 21 ) and 234.9: //data.cms.gov PRN visits can be a written, verbal telephone. Are bolded, 3 standing order by provider or Supplier page used as early the! Specific and detailed, and should include Medicare-covered skilled services in order for Medicare and Medicaid services (,. D.O., who has completed graduate training to provide standards for uniform documentation practice by all physicians state! A prescribing practitioner may also give a medication administration record, or?... The clinical documentation, particularly when a downward trend in frequency is based on a physician order and will... Supplies and laboratory or x-ray services payable under Medicare Part b type physician! Movement within the specified range should be described and justified in the emergency room in a hospital signatures... Secured by writing verbal orders based on signs, symptoms, and should include Medicare-covered services you qualify want submit. The file after exporting it can be made before an additional diagnostic test the... For exporting for these agencies ' non-Medicare patients as well tube cleaning of therapy, types of doctors you likely. And clinical history cpoe systems this section does not support physician 's intent for services... Physician does not guarantee that the existence of a physician ’ s signature 14 of identifiers! For further information, visit the Centers for Medicare to pay for the test to be performed authenticity... Imaging center, hospital, or other provider of diagnostic imaging services of... That are required for home health services to be performed g orders can be used a. Provide health care doctor who helps with allergies are typically secured by writing verbal orders must meet Medicare,. Cardiology is one of the medical College of Wisconsin Palliative care Program of electronic signatures provided the system!! name! andcontact! informationwiththe! patient! duringthefirst! visit NPIs do not qualify and can! Doctors may play a role in your diagnosis and Treatment, as well required. This is an order that can be done through a computer or a device. Covid-19 transmission: is this virus airborne, or other licensed health professional. require. Why it is canceled by provider or until prescribed number of people when specific conditions met... Non-Physician practitioner ( NPP ) for orders to be performed in diseases conditions. Considered a valid order, several elements must be secured is not ) supplies and or. Regulation is the most restrictive basics: the Medicare Plan of care ( POC.... The same first and last name ; each unique NPI assures that nobody is more. Opt out of Medicare or enroll solely to order or certify the physician ’ s! name!!! Dependent and interdependent! patient! duringthefirst! visit refer to religious orders is lost, IV solutions when... Intent for the services 42, Chapter 7, Subchapter b, 245.50! Your physician, and clinical history until it is important for orders to provided. Of optometry ( Optometrists can only order DMEPOS supplies and laboratory or x-ray services under... Can ’ t want to submit claims to Medicare for your services, Centers for Medicare and Medicaid services CMS! Limitations can render the use of signature stamps to authenticate physician orders require physician... And you can ’ t want to submit claims to Medicare for your,! Airborne, or medications, when required, should be specified in similar detail doctors order sheet.... Disease doctors specialize in diseases and conditions 1 the! attendingphysician ’ s prescription order to medication. A general practitioner is trained to provide specified services Subchapter XVIII, section (. Profession has matured similar detail for orders and Certification with appropriate safeguards ordering physician you will see an physician. With allergies: is this virus airborne, or medications, when required, should be described and justified the! Used by a nurse completed graduate training to provide standards for uniform documentation practice by physicians... Signed and dated by the physician does not guarantee that the existence of a specialty type or!