The medical assistant plays a major role in writing and maintaining patient records. These records document the evaluation and treatment given to the patient. Patient records are critical to the care of the patient. Without accurate and complete patient records, medical care could easily be compromised.

Patient records have many parts or sections that describe these facets of every patient:

• Personal information or data
• Physical and mental condition
• Medical history
• Medical care
• Medical future if the patient is referred to other physicians

In this chapter you will learn how to carefully manage the records of the patient. You will understand that if the medical care is not documented, in a legal sense, the med-ical care did not occur at all.

Outline

• Importance of Patient Records
• Contents of Patient Charts
• Initiating and Maintaining Patient Records
• The Six Cs of Charting
• Types of Medical Records
• Appearance, Timeliness, and Accuracy of Records
• Computer Records
• Medical Transcription
• Correcting and Updating Patient Records
• Release of Records

Learning Outcomes

After completing Chapter 9, you will be able to:

 9.1 Explain the purpose of compiling patient medical records.
 9.2 Describe the contents of patient record forms.
 9.3 Describe how to create and maintain a patient record.
 9.4 Identify and describe common approaches to documenting information in medical records.
 9.5 Discuss the need for neatness, timeliness, accuracy, and professional tone in patient records.
 9.6 Discuss tips for performing accurate transcription.
 9.7 Explain how to correct a medical record.
 9.8 Explain how to update a medical record.
 9.9 Identify when and how a medical record may be released.

Summary

The medical assistant must properly prepare and maintain patient records. Patient records, also known as charts, contain important information about a patient's medical history and present condition. Patient records serve as communication tools as well as legal documents. They also play a role in patient and staff education and may be used for quality control and research. The six Cs of charting are the client's words, clarity, completeness, conciseness, chronological order, and confidentiality.

You should be familiar with the most common methods for documenting patient information, which include the conventional, or source-oriented, and the problem- oriented medical record approaches. You must ensure not only that the medical records are complete but also that they are neat, legible, contain up-to-date information, and present an accurate and professional record of a patient's care.

Part of maintaining patient records includes transcribing physician's notes—that is, transforming spoken notes into accurate written form. In addition, you must know the guidelines for how to correct and update a patient record and how to legally release it to a third party by obtaining written consent from the patient.