Medical Assisting Guide to Medical Records

Although more paper documents are becoming electronic health records, there are instances when a paper document is needed and used, in this digital age. A medical assistant will still need to become familiar with paper document and their uses. Some examples include medical history surveys, consent forms, medical charts, letters and memos. The medical assistant is responsible for accurate documentation and maintenance of patient medical records. Without accurate and complete patient medical records, the patient can receive inadequate treatment. Patient medical records include personal information and data, physical and mental conditions, medical history, and current medical care. Patient medical records can serve as a communication tool and as legal documents.

Communication Tool

There are many uses for patient medical records. They can be used for patient education, to evaluate quality of care and to support medical research.

Patient Education – Patient medical records can be used to educate patients about their condition and the treatment plans created by the physician. By keeping accurate medical records, the patient and physician can follow the trend lines of many vital signs to understand if the patient is following treatment instructions.

Quality of Care – Patient medical records are used to evaluate the quality of care a physician provides. With the help of complete medical records, auditing teams can monitor whether the care and the fees for that care meet the accepted standards. Medical records can also be used to help improve future treatment by making better decisions.

Medical Research – patient medical records are important for researchers to compile information about a medicine or treatment and the outcomes. What side effects did the patient experience? What were the ultimate outcomes? Medical records can also spur new medical research by finding trends in the data that might not have been seen previously.

Legal Guidelines for Patient Medical Records

Patient medical records are important for legal reasons. If the information is not documented, then it can’t be proven that an event or procedure occurred. According to the Federal False Claims Act it is required that patient medical records be kept for 10 years.

All medical procedures, treatment, instructions and care must be documented. Since every entry into the patient medical record is legally binding, it must be written clear, accurate, legibly, dated, signed and per HIPAA guidelines. The physician and medical assistant should never include opinions on a medical record. If the medical records are incomplete and illegible than it can be suggested that the level of care the physician provided was also below standard.

The Six C’s of Medical Records

Medical assistants should memorize these six C’s to maintain accurate patient medical records. Client’s Words, Clarity, Completeness, Conciseness, Chronological Order and Confidentiality.

Client’s Words – a medical assistant should always record the patient’s exact words. They shouldn’t rephrase or summarize the sentence. The exact words will help the physician make a more accurate diagnosis.

Clarity – use accepted medical terminology when describing a patient’s condition.

Completeness – fill out all forms completely and provide complete information for any notations made in the medical record.

Conciseness – be brief and to the point. To save time, the medical assistant can use agreed upon abbreviations.

Chronological Order – the medical assistant must date all entries to document when they were made. This is important for documenting patient care and to resolve any legal questions about the medical services performed.

Confidentiality – all information in patient medical records is confidential and the information should never be discussed unless the medical assistant has the express written consent of the patient. The only exceptions are for medical personal that are performing direct care to the patient.

Complete and Understood Medical Records

It is just as important for medical professionals to understand the medical records as well as being complete. Medical records should be legible, timely and accurate.

Legibility – The use of medical transcription can be important to transfer written notes or dictation to electronic health records. The medical assistant will need to be familiar with standard abbreviations, medical terminology and medical coding. The medical assistant should always date and initial all transcription pages. All transcription should consider the six C’s to be accurate, complete, use proper grammar, correct spelling and accurate recording of abbreviations and medical terminology.

Timeliness – all medical records should be kept up-to-date and available for medical assistants and physicians to use in treatment of the patient. The medical assistant will want to record all exams and test results as soon as they are available. To document phone calls, the medical assistant will record the date and time of the call, the caller’s name and phone number, the information discussed and any results.

Accuracy – the medical assistant will want to check all medical records for accuracy to ensure accurate data and to provide proper care to the patient. The medical assistant should double check the accuracy of the findings and medical instructions recorded in the medical record. Also, they will want to make sure that the latest information has been updated to the medical record, so the physician has the most accurate data to make decisions.

Are you interested in learning more about the importance of medical records as 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 in starting a rewarding career.