Medical Office Management Study Guide for the Medical Assistant test

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Medical Records

There are four primary purposes for the medical record. It is a legal document, a record of treatment actions, a form of communication between healthcare professionals treating the same patient, and a research tool. The record should contain personal information as well as living will or power of attorney information.

Keeping Records Current

Any updates to a patient’s past medical history should be noted in the medical record as soon as they are known. All treatment should also be included in the record for a complete history of the illness or problem.

Documentation

When preparing any documentation for a patient’s medical record, it is important to use the correct medical terminology and to be able to translate that information into terms the patient understands. A medical record should include physician notes, nursing/assistant notes, laboratory records, radiology reports, and insurance information.

Subjective Data

Information you receive from the patients themselves is subjective data. This includes the chief complaint, current illness and symptoms, past medical history and family history, and a review of lifestyle, including occupational and social information.

Objective Data

Objective data, such as vital signs, laboratory results, and examination results will also be collected during a visit and should be entered into the medical record. Objective data is gathered from things you can observe or document during the office visit.

Treatment/Compliance

All courses of treatment, as well as the patient’s report of compliance, should be recorded in the medical record. This ensures that a complete record and history is maintained.

Confidentiality

Confidentiality policies should be reviewed and updated regularly. All employees of the office are responsible for keeping information secure and maintaining confidentiality. Records should be locked and charts should never leave the office. Phone calls and conversations should not be overheard by anyone. Additional confidentiality requirements may be necessary for certain illnesses, such as HIV. State regulations should be followed in these instances.

Scribe for Physician

A medical assistant may be asked to prepare (or transcribe from notes and records) verbal dictation. In instances of direct dictation, the assistant should type out exactly what is said and the physician should speak clearly and slowly, spelling names and addresses. When completed, the physician should review and sign it.

Charting Systems

There are several ways to chart a medical record. The problem-oriented medical record (POMR) contains the history and physical exam database, detailed patient problems, an educational diagnostic and treatment plan, as well as progress. This charting system makes it easy to follow a patient’s progress and treatment. A more traditional approach is the source-oriented medical record (SOMR). This type of record is divided into distinct sections. Examples include history and physical, progress notes, nursing/medical assisting notes, and laboratory/diagnostic testing.

Chart Organization

Chart organization is typically in reverse chronological order, meaning that the most recent information is on top and is the first that is viewed. Progress notes are usually written in a narrative format so that they are easily read by anyone. The information may be grouped with either a POMR or SOMR format but should include some or all of the following fields: history and physical, discharge summary, operative notes, diagnostic and lab results, progress notes, consultation reports, and related correspondence, charts, graphs, tables, and flow sheets.

Medical Record Management

Medical records must be kept in a secure area that does not allow other patients to see the records. The records must be accurate and follow all legal guidelines. Falsification of medical records is a criminal offense. The patient owns the information in a medical record and sharing it with anyone, including other physicians, must be consented to by the patient. The only exceptions to this occur when a subpoena has been issued by the court, the physician is being sued by the patient, or the disclosure of the information will protect the patient or a third party. Patients may request a copy of their files at any time.

Technology

Digital technology is becoming the standard for scheduling and maintaining patient records. Familiarity with all technology used in clinical operations is essential.

Basic Skills

Basic computer skills are necessary for entering data and accessing an electronic medical record (EMR). These skills include using word processing and spreadsheet software. Some facilities will provide training on basic computer skills to ensure that employees can save and retrieve files, as well as work in a manner that maintains confidentiality.

Hardware

Hardware refers to the physical components of a computing system, including the Central Processing Unit (CPU), monitor, mouse, keyboard, and printer. These devices are necessary for inputting and retrieving data. A backup system should be available in the event that the primary system fails.

Software

Software applications are the programs available in an office computer. You must use the hardware devices to access the software that contains pertinent information. Common types of software found on all computers include the operating system, word processing software, spreadsheet and database software, email, browsers, and presentation creation software. In a medical setting, you will also typically see the medical office software, which includes sections on billing, scheduling, electronic health and financial records, and patient portals.

Security and Confidentiality

As a part of the Health Information Technology for Economic and Clinical Health Act, a medical office must demonstrate “meaningful use” of electronic health records (EHRs) to receive financial incentives. Medical information in a digital format is still subject to security and confidentiality safeguards. This includes ensuring that everything is password-protected and will automatically log out or switch to a screen saver if not used in a certain time. Access should only be given to those individuals who need it to complete their duties. Patient data should be protected by an encryption firewall and the computer equipment should maintain an activity log to determine who has accessed it.

Troubleshooting

The medical assistant should be familiar with basic troubleshooting tasks to respond to an equipment failure. This will typically be effective for minor computer problems and errors. In the event of a major problem, it is best to get the IT staff to assist with solutions and repairs.

Other Devices

Other digital equipment may be necessary for certain medical assistant duties. Additional input devices to the computer, such as scanners and digital cameras, may be used to add and store data. Output devices, such as printers, allow data to be sent in a different format. Copiers and fax machines are also commonly used in the medical office environment. Tablets are becoming increasingly important for entering data as their small design allows for much easier transport.

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