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 problemoriented medical records approaches. You must ensure not only that the medical records are complete but also that they are neat and written legibly, contain up-to-date information, and present an accurate, professional record of a patient's case.

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 release it to a third party.