Importance Of Medical Records And Consent For Medical Assistants
One of the main tasks of medical assistants is to maintain and keep medical records and consent. Learning how to keep and maintain medical record is one of the requirements for licensing and or certification.
The medical assistant sees to it that the medical record of a patient must be ready every time the health practitioner sees him or her. In this manner the doctor can check the record and see what medicine he or she is currently giving his or her patients, what tests had been done and the lab results needed in diagnosing the patient. After which the recommendations, prescriptions, diets, procedures that was done to the patient on that session will be recorded by the medical practitioner. The medical assistant will see to it that the medical record will be put back to the filling cabinet. This way, the record is safe and secured. Lose pages must be secured and those who use the record must never tamper on the results.
Part of this role is ensuring who has rightful access to the record. The patient upon request can have a copy of his or her medical record. In case the patient becomes comatose, kids of legal age or brothers and sisters of legal age can access the record as long as they have written consent. During disaster cases, the doctor can see the record in order to save the patient. Medical records of children can be access by their parents or legal guardian if they don’t have parents. Also, researchers can access the record as long they got consent and there is a written record that the identity of the client will not be disclosed. Authorities may also access the medical record of a patient for some reasons but could not be charge base on the medical record.
The medical assistant being the record keeper must see to it that the copy of the medical consent for the medical practitioner that was given and signed by the patient is filed and secured. Nonetheless, prior to obtaining the consent of the patient, the medical practitioner must explain the surgery or course of action to the patient. The benefit and the side effect of it if any, other options and what happens if the patient will not have it. For some reasons complains and in some cases goes to court.
Medical record and consent are two legal documents in the health care business. It must be well secured.
Medical record includes all measures and treatments done to the patient from the early assessment to the present diagnosis. It contains the diagnostics and assessments made by the medical practitioner of the person’s physical, emotional and mental health. The person’s habit and way of living is also recorded and kept in file. Illegal access to it is a violation of the person privacy.
The second record is known as the consent. It is giving approval for the medical practitioner to conduct medical technicalities, surgery, therapy and others that require under the law consent. This record is very cardinal. It can protect the medical practitioner from complaint of medical malpractice.
Medical assistant truly needs to discern these two records because they are commonly used in the hospital. It may seem easy but it is not. To keep these records secure, the medical assistant must possess high level of decency and dedication in the job.
Medical assistant jobs and career advancement. Visit the links to discover what is a medical assistant and the different roles that a medical assistant is portraying.
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