The medical assistant plays a major role in writing and
maintaining patient records. These records document the
evaluation and treatment given to the patient. Patient
records are critical to the care of the patient. Without
accurate and complete patient records, medical care could
easily be compromised.
Patient records have many parts or sections that
describe these facets of every patient:
- Personal information or data
- Physical and mental condition
- Medical history
- Medical care
- Medical future if the patient is referred to other
physicians
In this chapter you will learn how to carefully manage
the records of the patient. You will understand that if the
medical care is not documented, in a legal sense, the medical
care did not occur at all. |