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. |