Most recent information should be on top in the medical record
The patient
Who ultimately decides if a medical record can be released?
Cost of space, Confidentiality requirements, Fire protection
Things a medical assistant should consider when selecting filing equipment
Chief complaint
Is the main problem patients are currently experiencing (Medical assistant should note other remedies the patient has tried, duration of the pain, and the time when symptoms were noticed
New file preparation
Make sure patients name is spelled correctly Review forms the patient fills out for completeness Make a copy of insurance card or make sure insurance information is included
"If it was not charted, it did not happen"
Medical assistant should remember about documentation
Power of attorney
A legal instrument that authorizes a person to act as the agent of the grantor
HIPAA
Does not recommend how many years a physician must keep patients records
Keeping records on minors
Until the age of maturity (18) plus 3 years
Draw a line through the error, date and initial
Correcting an error in the medical record
To protect the patient health and well-being
Importance of reporting to physician when an error in charting is discovered later
25%
Physician's using electronic health records in U.S.