Value Of Medical Records And Consent For Medical Assistants

One of the managerial functions of a medical assistant is maintaining medical records of the patient under the care of the medical establishment or health practitioner he or she is working with. Being able to maintain and file documents in an orderly fashion is one of the many things that medical assistants must learn to master.

The medical assistant sees to it that the medical record of a patient must be prepared every time the medical practitioner sees him or her. In other words, it is easier and more orderly if the medical assistant knows how to file the documents well. As soon as the medical practitioner is done seeing and checking the client, he will record his new findings in the medical record. The MA must see to it that the orders are carried ouf and the record is kept accordingly. In that way it is safe. Losing any page, unauthorized accessing and tampering must be avoided at all times.

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 that the patient is unable to make personal decisions like a comatose patient, kids of lawful age, brother or sister of legal age, nearest relative or legal guardian may access the medical record. During emergency cases, the medical doctor can see the record in order to save the patient. Meanwhile, medical records of children can be access by parents or their legal guardians. Medical researchers can access the medical record if the research that they are doing is relevant to the illness of the patient but without disclosure of the identity of the patient. Authorities can also access the medical records of the patient but they can never chage base on the medical record alone.

The medical assistant being the record custodian 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. Regardless, before obtaining the consent of the patient, the medical practitioner must explain the surgery or course of action to the patient. The advantage and the adverse 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.

The medical record and the medical consent of the patient are two legal records that must be well secured.

The first is the record of the patient, going back from the first time the patient went to see the health practitioner for consultation or medical support. 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. Unauthorized access to it is a violation of the person privacy.

The second record is the medical consent, a written consent of the client. It is giving consent for the medical practitioner to conduct medical procedure, operation, rehabilitation 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 understand these two records because they are commonly used in the hospital. This task may seem easy but it is not. To keep these records secure, the medical assistant must possess high level of integrity and dedication in the job.

By: Daryl B. Chapman

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