Charting is an integral part of a medical assistant’s job. Everything in healthcare is documented, and accuracy is a must. Medical charting has a unique set of rules that differ from other types of written communication. Let’s explore the basics of documentation and how medical assistants can improve their medical charting.
What is Medical Charting?
A chart is a complete record of a client’s demographic and clinical information, including:
- Health history
- Diagnoses
- Medications
- Immunizations
- Allergies
- Diagnostic test results
- Exam notes
- Treatment plans
Every time a patient calls or visits, the record is updated to reflect the most current information. This is called medical charting, and it’s imperative to quality care.
Why is Medical Charting Important?
Charting is important for several reasons, especially for continuity of care, because tracking medical changes over time is critical. Any physician should be able to review a patient’s record and understand how past care shapes their present health. Electronic medical records make it possible for an emergency room physician in California to get information from a patient’s doctor in Maine, enabling them to make better treatment decisions if the data is accurate.
Medical charting also supports reimbursement. Coding is part of charting and is used by insurance companies to determine coverage. A majority of healthcare bills in the United States are paid for by third parties, so inaccurate coding or lack of supporting documentation could lead to payment delays and unexpected bills for patients.
Finally, medical charting protects you and your employer against liability in the event of a complaint. The rule in healthcare is, if it wasn’t documented, it wasn’t done. A record of events is sometimes necessary to prove standards of care were followed.
Types of Medical Charting
Everyone who provides direct patient care is expected to update the chart, each team member is responsible for writing their own notes. Medical assistants document demographics, medical history, health screenings, vital signs, care notes and billing and coding information.
Demographic Changes
Medical assistants verify patients’ demographic and billing information at check-in, initiating a visit record.
Medical History
Medical assistants conduct brief reviews of a patient’s medical history, including updating medication, allergy and immunization lists, at the start of each encounter.
Health Screenings
Routine health screenings are a part of most exams. Medical assistants gather helpful information about patients:
- Depression symptoms
- Tobacco, alcohol and drug use
- Home safety needs
Doing these screens in advance pinpoints items of concern for the doctor to address.
Vital Signs
Vital signs are a window to patient health. Medical assistants measure blood pressure, heart rate, respiration and oxygen saturation at each visit. Accuracy is crucial because changes in trends over several years can point to conditions such as hypertension.
Care Notes
Medical assistants should document any personal care they provide, anything significant the patient tells them, and how they acted on the information.
Billing and Coding Information
Some medical assistants code documentation, others collect supporting data and let billing specialists handle the rest. Codes are a form of alphanumeric shorthand that describes symptoms, diagnoses and treatments, cutting down on the volume of data that must be exchanged. The three coding systems medical assistants use are:
ICD-10 – short for the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, these codes classify every known symptom, injury and medical condition. Insurance companies use them to make coverage decisions. Public health officials track them for statistical purposes.
CPT -Common Procedural Codes (CPT), are numeric sequences categorizing all diagnostic, medical and surgical procedures, they’re used for reimbursement and to monitor treatment outcomes.
HCPCS -Healthcare Common Procedure Coding System (HCPCS), was designed exclusively for Medicare and codes medical equipment and ancillary services such as ambulance transportation.
A small portion of insurance claims are initially denied for inaccurate coding, doubling the work of billing staff to fix. Making sure they’re correct the first-time matters.
How Can Medical Assistants Improve Their Medical Charting?
A medical assistant’s documentation should be as clear and accurate at possible. Follow these guidelines:
1) Use only approved medical abbreviations. Regulators require all healthcare facilities to have a standardized list, it’s a proven way to eliminate confusion and enhance safety. Never use abbreviations on patient education material.
2) Date all entries. Electronic medical software does this for you in most instances, but occasionally, documentation on paper is required. Always note the date and time care is provided.
3) Be timely. If you forget to document something, it’s acceptable to make a late entry. However, until the entry is made, no other team members are aware of the data it contains, potentially affecting care.
4) Be brief. Reading notes with irrelevant information is time-consuming, include all pertinent data but keep them concise.
5) Make clear corrections. Write only in blue or black pen and never erase or alter entries without an explanation, medical records are legal documents. You can correct errors on handwritten forms by drawing a single line through them followed by your initials. Avoid obscuring the initial entry because if it can’t be read, it could be questioned in court. Never chart early to avoid having to make corrections if something changes.
6) Write legibly. While computerized record-keeping has eliminated most problems with messy handwriting, paper records must be legible.
7) Record the patient’s words. Nothing is more accurate than what a patient says. Avoid embellishing notes with opinions, subjectivity is vulnerable to misinterpretation.
8) Stay within your scope of practice. Don’t document on subjects you have no training in or that are beyond your legal responsibilities, and never chart for someone else.
9) Double-check documentation. The easiest way to correct errors is not to make them. Take your time when charting, verifying data as you go.
Final Thoughts
Health doesn’t happen, it evolves. Medical charting can seem like busywork when the waiting room is full, but doctors can’t prescribe the best treatments if they don’t have the whole story. Visits build on each other to form a clearer picture of a patient’s well-being, making quality charting among a medical assistant’s most vital responsibilities.
Did learning about how to improve medical charting interest you? 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.
Contact us to learn more about how you can become a medical assistant today.