Medical Records Management

The Medical Administrative Assistant should take the following steps to establish a patient’s medical record:
Determine the patient’s status in the office (New or Established)
Obtain the required general information
Enter the information into the patient history form Review the form for accuracy
Enter the patient’s name into the computerized ledger
Assemble the appropriate forms, prepare the folder and file as necessary
Components of the Medical Record
Personal and Medical History Created using information gathered from the patient. Usually includes information such as past illnesses, surgical operations, and the patient’s daily health habits.
Patient’s Family History
This information is just as important as the patient’s personal and medical history. Includes information regarding the health of members of the patient’s family, and a record of the causes of death.
Patient’s Social History
Includes information regarding the patient’s lifestyle.
Ex: Smoking and Drinking Habits
Patient’s Chief Complaint
A statement of the patient’s symptoms.
Diagnosis
A decision made based on the information regarding the patient’s history and the results of the doctor’s examination
Problem Oriented Medical Record
SOAP Approach A format for progress notes based on the letters of the word:
S: Subjective Impressions
O:Objective clinical evidence
A:Assessment or Diagnosis
P: Plans for further studies, treatment, or management
Filing
Indexing
The Medical Administrative should use the following indexing rules:
1. Last Name, First Name, Middle Name/Initial
2. The hyphenated portion of a name is used as one unit
Ex: Anna Smith-Meyer is filed as Smith-meyer, Anna
3. Apostrophes are not used in filing
4. Titles, and terms of seniority are only used to distinguish from an identical name
5. When indexing a company, articles such as “The” and “A” are not used
Ex: The Mandarin Office is filed as: Mandarin Office
Alphabetical Filing
Folders are arranged in the same sequence of the alphabet
The medical assistant must ensure that the filing cabinet has enough space for proper distribution of the files amongst each letter of the alphabet
Numerical Filing
An alphabetic cross-reference is used to categorize materials with digits
Patients are assigned in a consecutive number
Records are filed backwards in groups
Records are filed backwards in groups
Subject Filing
Either an alphabetic or alphanumeric code is assigned to general correspondence
Tickler File
A collection of date labeled file folders used as a reminder for time sensitive matters or other important information
Tickler File
Used as a follow up method
Tickler File
Should be checked each day