Chapter 9 - Maintaining patient records. In this chapter you will explain the purpose of compiling patient medical records, describe the contents of patient record forms, describe how to create and maintain a patient record, identify and describe common approaches to documenting information in medical records,. | 9 Maintaining Patient Records 9- Explain the purpose of compiling patient medical records. Describe the contents of patient record forms. Describe how to create and maintain a patient record. Identify and describe common approaches to documenting information in medical records. Learning Outcomes 9- Learning Outcomes (cont.) Discuss the need for neatness, timeliness, accuracy, and professional tone in patient records. Discuss tips for performing accurate transcription. Explain how to correct a medical record. 9- Learning Outcomes (cont.) Explain how to update a medical record. Identify when and how a medical record may be released. Discuss the advantages and disadvantages of the electronic medical record, also known as the electronic health record. 9- Introduction Medical records document the evaluation and treatment of patients Critical to patient care Sectioned to describe various aspects of patient information | 9 Maintaining Patient Records 9- Explain the purpose of compiling patient medical records. Describe the contents of patient record forms. Describe how to create and maintain a patient record. Identify and describe common approaches to documenting information in medical records. Learning Outcomes 9- Learning Outcomes (cont.) Discuss the need for neatness, timeliness, accuracy, and professional tone in patient records. Discuss tips for performing accurate transcription. Explain how to correct a medical record. 9- Learning Outcomes (cont.) Explain how to update a medical record. Identify when and how a medical record may be released. Discuss the advantages and disadvantages of the electronic medical record, also known as the electronic health record. 9- Introduction Medical records document the evaluation and treatment of patients Critical to patient care Sectioned to describe various aspects of patient information and care Legal documents Medical assistant has a major role in documenting in and maintaining patient records 9- Importance of Patient Records The patient’s chart Past and present medical conditions Communication tool for health-care team Plan to provide for continuity of care Documentation for billing and coding Patient education and research Legal document admissible in court 9- Importance of Patient Records (cont.) Information included in patient record Name and address Insurance coverage and person responsible for payment Occupation Medical history Current complaint Health-care needs Medical treatment plan Response to care Lab and radiology reports 9- Legal Guidelines for Patient Records 9- Standards for Records Complete, accurate, and well-documented records are evidence of appropriate care Incomplete, inaccurate, altered, or illegible records may imply a poor standard of care Everyone who documents in the patient record has a responsibility to
