Importance of Patient Records
{"Image DocumentName": "Importance of Patient Records", "Image ImageDescription": "Legal Guidelines for Patient Records. Standards for Records. Additional Uses of Patient Records. Patient Education. Quality of Care. Research. Learning Outcome: 15.1 Explain the importance of accurate patient medical records. One of the most important duties of an administrative medical assistant is initiating and maintaining accurate and thorough patient records. Patient records, also known as charts, contain important information about a patient\u2019s medical history, present condition, and treatment plans. The medical record in either paper or electronic format is initiated by the administrative medical assistant or another staff member and is consistently updated whenever the patient has contact with the office. The medical facility owns the physical record in either its paper or electronic format, but the patient owns the information contained within that record as it is his information. The patient chart, whether paper or electronic, provides physicians and other medical care providers with all the important information, observations, and opinions that have been recorded about a patient. The medical record serves as supporting documentation for billing and coding purposes and as a legal document that is admissible in a court of law. The overarching guidelines and standards apply to both hard copy and the EHR. Medical records include the following general information about the patient: Address and phone number. Occupation. Patient medical history. Past, family, and social histories. Current complaint or condition. Health-care needs. Medical treatment plan or services received. Medical imaging and laboratory reports. Response to care. Legal Guidelines for Patient Records. Patient records are important for legal reasons. As a general rule, if information is not documented, no one can prove that an event or procedure took place. Medical records are used in lawsuits and malpractice cases to support a patient\u2019s claim of malpractice against a doctor and to support the doctor in defense against such a claim. Medical records must be kept for 7 years and pediatric records for 7 years past the age of majority. Because financial records must be kept for 10 years and medical records must back any billing records, many legal experts suggest that medical records should also be kept for 10 years instead of the legally required 7. All medical care, evaluation, and instruction given to the patient by the physician must be documented. Every chart entry must be clear, accurate, legible, and dated. The patient chart is a legal document. Always consider how the patient record would present if it was called into a court of law for review. Additionally, it is very important to document when a patient is noncompliant . Noncompliant is a medical term used to describe a patient who does not follow the medical advice he or she is given. After a clear record has been made of the directions given to a patient for optimum health, it is essential to record the level of patient compliance. The physician may wish to withdraw from the care of a patient because of the patient\u2019s noncompliance. Without a proper and accurate documentation of the patient\u2019s noncompliance, the physician may not be able to withdraw care without becoming legally liable. Additionally, documented noncompliance can be used in the physician\u2019s defense in a malpractice suit if it can be proved that, due to patient noncompliance, the physician was not solely responsible for inadequate medical care or result. Standards for Records. Records that are complete, accurate, and well documented can be convincing evidence that a doctor provided appropriate care. On the other hand, altered, incomplete, inaccurate, or illegible records may imply that a doctor\u2019s entire medical practice is below standard. If an employee of the practice charts inappropriately or inaccurately in a patient\u2019s chart, the physician is held legally responsible for that action. All records, both medical and financial, are the responsibility of the physician. As the administrative medical assistant, you are responsible to the patient and the physician for any administrative procedures you perform and the accurate recording of those procedures. Additional Uses of Patient Records. Each patient record serves as an ongoing reference about that individual s medical care. It is also a valuable resource for patient education, quality of patient care, and research. Patient Education. A patient\u2019s record can be used to educate the patient about medical conditions and treatment plans. The physician can point out how test results have changed or how the patient\u2019s general health has improved or worsened. The physician can also emphasize the importance of following treatment instructions. The record may also be used to educate the health-care staff about unusual medical conditions, patient progress, or results of treatment plans. Quality of Care. The patient record may also be used to evaluate the quality of patient care provided by a physician or facility. Auditing groups, such as peer review organizations or The Joint Commission (TJC), may review select patient charts to monitor whether the care provided and the fees charged meet accepted standards. Records also provide statistics for health-care analysis and future health-care plans and policy decisions. Research. Some patient records may also play an important role in medical research. Carefully kept medical records are valuable sources of data about patient responses, behavior, symptoms, side effects, and outcomes. Information in charts may spur researchers to begin a study.", "Image XResolution": "37", "Image YResolution": "37", "Image ResolutionUnit": "Pixels/Centimeter", "Image Software": "SlidePlayer", "Image YCbCrPositioning": "Centered"}