Interested in learning more about how medical assistants document patient information in charts and records? There’s a saying in healthcare, and specifically around documentation of records, that if it isn’t written down and recorded, it didn’t happen. Maintaining accurate records is vital so there is a clear account of a case history. This is also crucial for the next person looking at those documents and charts after you to know what has been done. There are 5 ways for medical assistants to improve their documentation skills, they include being accurate and succinct, not being judgmental, using only appropriate abbreviations, clearly marking mistakes, and recording conversations.
Be Accurate and Succinct
Good documentation is an art. It is vital to be specific and keep to the point. Recording essential detail such as vital signs, pain control and a change in condition are a must. Be descriptive and set out what happened and what was done about it, particularly when escalating a problem. If you take blood or another sample from a patient, record the time and date it was taken. This stops a repeat of the same test and alerts the next person looking after the patient to look for the results. It also means that the patient or insurance company will get billed properly. The medical assistant will want to record the correct date and time in records.
Don’t be Judgmental
When documenting records, the medical assistant should be factual without making assumptions. They shouldn’t write opinions about a patient like “difficult patient.” This can get them into trouble not only with their manager but also the patient and their family. Patients can request to see their notes and finding something unpleasant about them is not professional, especially if their behavior is a symptom of their illness.
Use Appropriate Abbreviations
The healthcare sector tends to use abbreviations, but they don’t always have the same meaning in every organization? Take BID as an example. On a prescription, it can mean bis in die or twice daily in Latin. It can also stand for brought in dead. The medical assistant should always write something in full unless there is an accepted form of abbreviations used in the organization. Remember that what is a commonly used abbreviation in one organization may have an entirely different meaning in another.
Clearly Mark Mistakes
Sometimes medical assistant writes something down and realizes they made a mistake, or there’s a spelling error they need to correct. If the medical assistant is typing, it is easy to delete and start again. If they are using a handwritten document, they will need to put a line through the mistake, initial it and start again. They should not use Tippex or stick paper over the mistake. Removing notes looks suspicious in medical records. Also, the medical assistant should try to write in blue or black pen, so the records can easily be photocopied.
If the medical assistant has a conversation with a member of a patient’s family or the patient, it is important to write down what was said, particularly if there were instructions or concerns about care. This means that subsequent staff can see what has been communicated. If the medical assistant gives telephone advice, they should make sure to document this too, as well as noting the date and time of the call.
Documenting care and keeping accurate records is a vital component of the work of a medical assistant. By getting it right the medical assistant will be helping colleagues and ensuring the patient’s needs are being met.
Does documentation in medical assisting interest you? Are you interested in becoming a medical assistant? Gwinnett Colleges & Institute offers medical assisting courses to gain essential skills and training. The core curriculum focuses on the medical assisting skills and training you will need to seek entry-level employment in physicians’ offices, clinics, hospitals, and other medical settings needing the services of associates trained in both front and back office medical assisting skills. These medical assisting courses will be the first step to starting a rewarding career.