Medical records are made up of many different sections that describe a patient’s health, including personal information and data, physical and mental condition, medical history, current medical care, and future medical care.
The patient’s medical records serve two uses. The first is to document medical care for the patient, and the second is to serve as a legal document.
There are specific coding schemes a medical office administrative assistant must master to manage medical office records. While some forms are easier to manage as paper documents, much of what the medical office administrative assistant will maintain is in an electronic format. The medical office administrative assistant must also adhere to HIPAA confidentiality guidelines during medical records management tasks.
Legal Guidelines for Patient Medical Office Records Management
Patient medical office 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 managed for 10 years.
All types of medical procedures, treatments, instructions, and care must be documented. Since every entry into the patient’s medical office record is legally binding, it must be written clearly, accurately, legibly, and should be dated and signed in accordance with HIPAA guidelines.
The physician should never include opinions in a medical record. If medical records are incomplete and illegible, then it can be suggested that the level of care the physician provided was below the standard of care. Medical office records that are complete, accurate, and well documented are evidence that a doctor provided the appropriate care to a patient.
Types of Patent Medical Records
There are many different types of forms that a medical office administrative assistant will manage. The patient registration form, patient medical history, physical examination forms, laboratory results, diagnosis and treatment plans, operative reports, records of follow-up visits and telephone calls, hospital discharge summaries, consent forms, and correspondence with or about the patients are all documents that they may deal with.
Patient Registration Form – The patient registration form is an initial form that includes basic demographic information—patient’s legal name, address, phone number, and date of birth—as well as medical insurance information, emergency contacts, and primary care physician.
Patient Medical History – The patient’s past medical history includes illnesses, surgeries, allergies, current medications, family medical history, and social habits. The social habits include nutritional diet, exercise, use of tobacco or drugs, and consumption of alcohol.
Physical Examination Form – The physical examination form is a record of the patient review of systems and the results of a general physical examination. The questions asked during the general physical examination are used to identify any signs or symptoms that may alert the physician to any illness or conditions. The medical assistant will follow up the form with an examination of the patient’s vital signs.
Laboratory Results – These are the results of tests performed in the physician’s office or hospital or by independent sources. A flow sheet can be used for the physician to easily detect and manage abnormalities in ongoing testing.
Diagnosis and Treatment Plan – The diagnosis and treatment plan is recorded in the patient’s medical office record. This will include treatment options, the treatment option selected, instructions to the patient, and medications prescribed.
Operative Reports – Any procedures and surgeries are reported in the medical report. These include any notes made by the physician or medical assistant during the procedure.
Follow-Up Visits – Follow-up care is documented after a procedure or surgery.
Telephone Calls – Phone calls between visits may be added to the medical office record. These can be added in chronological order or as a log of telephone contacts.
Hospital Discharge Summaries – These include information that summarize the patient’s visit to the hospital, including tests, procedures, operations, medications administered, and the outcome of the patient’s visit.
Consent Forms – A signed informed consent must be obtained before any procedure is performed on a patient. The patient must understand the treatment offered, the outcomes that are possible, and any side effects of the treatment.
Correspondence with or About a Patient – All written correspondence from or about the patient must be kept in the patient’s medical office record. Each document should be stamped with the date of receipt. If information is received by fax, the sender is responsible for sending the original document in the mail.
Medical Records Management Types
There are many different ways to document and manage patient information, including source-oriented medical records, problem-oriented medical records, SOAP documentation, and CHEDDAR format. Source-oriented and problem-oriented are the most common ways to document patient information in medical records.
Source-Oriented Medical Records – With source-oriented medical office records, patient information is arranged in the medical chart according to who supplied the data. The information could have come from the patient, physician, medical office administration assistant, hospital, laboratory, or other medical facility. The medical records are arranged in chronological order.
A drawback to this type of documentation occurs when a patient experiences the same condition or illness multiple years apart. Information about historical conditions can be left in older sections of the medical office record and may not be seen by the attending physician.
Problem-Oriented Medical Records – Problem-oriented medical office records use a database of the patient’s past medical history, any information from the initial interview, all findings and results from all physical examinations, any tests, x-rays, or other medical procedures. Then, a problem list is created to give each condition or diagnosis a different number and the date it began.
Each problem will have a detailed educational, diagnostic, and treatment summary. Finally, progress notes are included for the management of each problem in the list. The progress notes are recorded in chronological order.
SOAP Documentation – SOAP stands for subjective, objective, assessment, and plan. This information is recorded in that specific order.
Subjective data comes from the patient as he/she describes signs and symptoms. Objective data comes from the physician, examinations, and test results. Assessment includes the diagnosis and impression of a patient’s problem. Finally is the plan of action for treatment options, medications, tests, patient education, and follow-ups.
CHEDDAR Format – CHEDDAR stands for chief complaint, history, examination, details, drugs and dosages, assessment, and return visit.
How Records Are Coded
There are three different types of medical coding that the medical office administration assistant will use in day-to-day tasks. They include ICD-10, CPT, and HCPCS.
ICD-10 Coding – The use of ICD-10 helps standardize medical coding internationally. The International Classification of Diseases (ICD) is used to record diagnoses by physicians and other medical professionals. ICD consists of alphanumeric codes that follow an international standard, making sure that diagnoses are interpreted the same way by every health care professional who treats patients.
CPT Coding – Current Procedural Terminology (CPT) coding is a U.S. standard for coding medical procedures maintained by the American Medical Association (AMA). CPT identifies the services provided and helps determine how much physicians will be paid for their services by insurance companies.
HCPCS – Healthcare Common Procedure Coding System (HCPCS) is a set of health care procedure codes based on the AMA’s CPT system. HCPCS is a medical billing process used by the Centers for Medicare and Medicaid Services (CMS).
The HCPCS coding system was created to standardize the coding of specific items and services provided by health care professionals and billed to Medicare and Medicaid. The HIPPA Act of 1996 made the use of HCPCS coding mandatory for processing insurance claims through Medicare and Medicaid.
The Six C’s of Medical Records
Medical office administrative assistants should memorize these six C’s to maintain accurate patient medical records. They are client’s words, clarity, completeness, conciseness, chronological order, and confidentiality.
Client’s Words – Medical office administrative assistants should always record the patient’s exact words. They shouldn’t rephrase or summarize sentences. The exact words will help the physician and medical assistant completely understand the condition of the patient and better manage their symptoms.
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 office record.
Conciseness – Be brief and to the point. To save time, the medical office administrative assistant can use agreed upon abbreviations.
Chronological Order – The medical office administrative 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 office administrative assistant has the express written consent of the patient. The only exceptions are for medical personnel who are providing direct care to the patient.
Electronic Versus Paper Files
Almost 87 percent of office-based physicians use some form of EHR system, according to the Centers for Disease Control and Prevention (CDC). Electronic health records (EHR) include a patient’s medical history, billing information, test results, and other health information managed digitally and accessible by all medical professionals with access.
This type of record is kept virtually and can be shared with other health care professionals to help provide the best care for a patient. Instead of having a specific room in a doctor’s office or other health care setting designated for holding thick files of paper medical records, the records are kept in cyberspace and are tightly secured.
A medical office administrative assistant will still need to become familiar with the different types of paper medical documents and their uses. Some forms are still used in paper format, including for example, medical history surveys, consent forms, medical charts, letters, and memos.
The medical office administrative assistant is responsible for accurate documentation and maintenance of patient medical office records. Without accurate and complete patient medical office records, the patient may receive inadequate treatment.
Want to learn more about the different types of records management and the medical office administrative assistant? Ready for an exciting new career in the health care field?
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