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. Medical assistants can make some common mistakes during documentation. However, 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. Repeated procedures are a common mistake made by medical assistants that don’t follow proper documentation. 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, to not make these common mistakes.
Don’t be Judgmental
When documenting records, the medical assistant should be factual without making assumptions. A common mistake medical assistants are guilty of is writing 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.
Making Mistakes as a Medical Assistant
After a successful career as a student, it’s tough for a medical assistant to suffer their first on-the-job failure. Making an error, especially if it’s a serious one, can cause a crisis of confidence. If it continues, a medical assistant may become tentative and second-guess their decisions, making their job stressful and in some cases, impossible.
As a trait, confidence is hard to quantify, but as a skill, it’s easy to cultivate by remembering that no one is perfect, and that failure can sometimes be the best teacher. It takes confidence to become a medical assistant, nurture it by setting realistic goals and allowing room for mistakes.
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.
Don’t Work Beyond A Skill or Certification Level
A medical assistant has strict guidelines and there are laws that they must abide by. A common mistake that a medical assistant may be guilty of is documenting something they are not certified in or trained properly on. This can cause confusion and errors in documentation. If the medical assistant is unsure about a term or abbreviation, they should ask for clarification.
Double Check Others Documentation
It is important to double check other medical assistant’s documentation regularly, especially those entry-level medical assistants. They can make common mistakes in documentation, and by catching them before they are submitted as a claim, a senior medical assistant can help avoid the hassle and possible patient complications.
Documenting care and keeping accurate records is a vital component of the work of a medical assistant. A medical assistant may make a few common mistakes. But, 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.