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Chapter 10 Appointments and Schedules 211
Exercises and Activities
Certication Preparation Questions
1. Which of the following would best represent a
third-party payer?
a. Patient’s parent paying for services
b. Friend paying for a patient’s services
c. Insurance company
d. Patient being seen by three different providers
e. Patient being seen at a free clinic
2. The term precertication means:
a. the insurance company guarantees to pay for the
service/procedure.
b. the insurance company approves the service/
procedure but does not guarantee payment.
c. the insurance company has veried coverage for
the patient.
d. the facility performing the procedure/service is
certied in for the testing to be performed.
e. the person performing the procedure/service is
in the process of certifying his or her skills.
3. Constellation of symptoms is best described as:
a. a collection of random symptoms.
b. symptoms that occur only at a specic time of night.
c. certain symptoms occurring together that signal
a particular condition.
d. symptoms randomly occurring together without
reason.
e. a group of symptoms that never occur together.
4. Which of the following best explains a consultation?
a. A consultation is when a physician asks another
physician to assist in the managing of a patient’s
case.
b. A consultation is when a physician refers the
care of a patient to another doctor.
c. A consultation is when a physician talks with his
or her patient about their routine care.
d. A consultation occurs only when a patient is in
the hospital.
e. A consultation can only occur if the patient
requires surgery.
5. The term double-booking, in scheduling, means:
a. to assign an amount of time to an appointment
based on the type/reason for appointment.
b. to allow the same amount of time for every
appointment regardless of type/reason.
c. when a group of patients are scheduled for the
same block of time and are seen in order of arrival.
d. when patients are scheduled on a particular day of
the week based on the reason/type of appointment.
e. when two patients are given the same appoint-
ment time.
6. The term STAT means:
a. as soon as possible.
b. sometime today.
c. within 48 hours.
d. immediately.
e. as directed.
7. What is a preferred provider?
a. Physician/provider that the patient prefers over
others in the plan
b. Physician/provider who does NOT participate in
a particular insurance plan
c. Physician/provider who is preferred by the refer-
ring physician
d. Physician/provider who participates in a partic-
ular insurance plan
e. Physician/provider who is preferred by the refer-
ring hospital
8. The term streaming, in appointment scheduling,
means:
a. to assign an amount of time to an appointment
based on the type/reason for appointment.
b. to allow the same amount of time for every
appointment regardless of type/reason.
c. when a group of patients are scheduled for the
same block of time and are seen in order of
arrival.
d. when patients are scheduled on a particular
day of the week based on the reason/type of
appointment.
e. when two patients are given the same appoint-
ment time.
9. When scheduling a patient the minimum
information you need is:
a. name, address, and phone number.
b. name, address, and reason for the visit.
c. name, address, and insurance information.
d. name, phone number, and reason for the visit.
e. name, phone number, and insurance information.
10. The abbreviation NPT stands for:
a. next patient time.
b. new patient time.
c. new provider today.
d. next patient.
e. new patient.
212 Section III Administrative Medical Assistant Skills
P
S
Y
CareTracker Connection
Appointments and Scheduling
CareTracker Activities Related to
This Chapter
Case Study 3: Entering Appointments and Referrals
r
One of the greatest challenges medical assistants face
is effectively managing the schedule of the medical
ofce. Busy health care providers with unexpected
schedule changes and patients who show up late or
not at all can keep you scrambling to maintain order
and sanity. Computerized appointment scheduling systems, such as the one included in CareTracker, can be
a lifesaver.
Tasks discussed in this chapter that can be performed
in CareTracker include the following:
Creating templates for various types of appointments
r
Checking provider and resource availability
r
Preparing a daily schedule of appointments for each
r
provider
Scheduling patient appointments of various types
r
Double-booking patient appointments
r
Rescheduling patient appointments
r
Cancelling patient appointments
r
Adding a patient to the wait list
r
Scheduling consultations and referrals
r
Scheduling the use of resources, such as meeting
r
rooms or equipment
Recalling patient appointments
r
A task we’ll consider here is scheduling a sick visit for
an established patient.
When a patient calls the medical ofce requesting an
appointment with a health care provider, the rst step is
to check that provider’s schedule for the day in question.
In CareTracker, this involves opening the Scheduling
module and entering the desired date and provider. The
corresponding schedule will then be displayed.
Chapter 10 Appointments and Schedules 213
To book an appointment, you then click in the eld next
to an available time slot, and the Book Appointment window will appear. You select the appropriate appointment
type, select the patient’s chief complaint, and add any relevant notes.
Once you save the appointment, it will appear on the
schedule.
You’ll get a chance to practice this task in Case Study
3: Entering Appointments and Referrals.
To access Case Study 3, go to http://thepoint.lww.
com, log in using your username and password, search
for The Complete Medical Assistant, click on “Student
Resources,” nd the Harris CareTracker materials, and
click on “Case Study 3.”
Medical Documentation
11
Chapter Objectives
● List information contained in a medical record.
● Establish and maintain the medical record.
● Contrast the ways in which medical records can be
organized.
● Discuss security of medical records.
CAAHEP & ABHES Competencies
CAAHEP
● Dene types of information contained in the
patient’s medical record.
● Identify methods of organizing the patient’s medical
record.
● Identify equipment and supplies needed to create,
maintain, and store medical records.
● Describe ling indexing rules.
● Differentiate between electronic medical records
(EMR) and a practice management system.
● Create a patient’s medical record.
● Organize a patient’s medical record.
● File patient medical records.
● Utilize an EMR.
● Explain how to make entries in a patient’s medical
record.
● Describe how to make corrections in medical records.
● Document appropriately.
● Explain proper access and use of medical records.
● Input patient data utilizing a practice management
system.
● Explain the importance of data backup.
● Explain meaningful use as it applies to EMR.
ABHES
● Utilize electronic medical records (EMR) and
practice management systems.
● Comply with federal, state, and local laws relating
to exchange of information.
● Describe elements of meaningful use and reports
generated.
● Demonstrate understanding of records
management.
Chapter terms
Chapter 11 Medical Documentation 215
Active records
Assessment
Closed records
Consultation reports
Database
Flow sheet
Inactive records
Narrative style
Abbreviations
CC
EHR
EMR
Case Study
Matthew McNeil came into the ofce today for
follow-up after passing a kidney stone. A week
ago, he went to the emergency room where he
was treated and advised to follow up with his pri-
mary physician. During his visit, Mary, his medi-
cal assistant had to leave the room to get a blood
pressure cuff. Mary, knowing she would be right
back, left the computer open to Mr. McNeil’s chart.
Matthew saw the record open and began read-
ing in his chart. He remembered that his wife had
FMH
HPI
POMR
Numeric ling systems
Objective
Progress note
Radiographic reports
PMH
ROS
SH
been in recently and was awaiting lab result so he
decided to search her name. He located his wife’s
chart and her laboratory results. Mary returned to
the room to nd Mr. McNeil on the computer viewing his wife’s laboratory results. Mary reported
this incident to the ofce compliance ofcer, who
in turned called Mrs. McNeil to report the details
of the occurrence. Mary had to attend additional
compliance training to insure such events do not
occur in the future.
Secondary records
Subject ling
Subjective
Worker’s compensation
SOAP
SOMR
Working with patients’ medical records is one of the
most important jobs you’ll have as a medical assistant.
A fair amount of your time will be spent entering notes,
documenting procedures, and scanning documents into
the patient’s record. A medical record is a form of communication as well as a legal document. It provides condential information about a patient’s health to those
qualied to access it while also serving as evidence of
the care the patient has received. Good medical records
are vital to the smooth operation of any medical ofce.
Physicians and other staff must be able to access a
patient’s chart quickly while insuring the information is
protected. In this chapter, you’ll learn how to organize
and maintain patient records. You’ll also learn about
managing medical records systems.
C
O
G
Medical records are a critical part of health care. A
patient’s electronic medical record can be referred to as
an EMR (electronic medical record), EHR (electronic
MEDICAL RECORDS
health record), or patient’s chart. This record contains
the history of a patient’s involvement with your ofce.
It’s the ofcial record of the following things:
The physician’s evaluation of the patient’s health
r
Treatments carried out on the patient
r
Changes in the patient’s medical condition
r
Communication between the patient and the staff
r
Information contained within the record is condential and can’t be shared with others unless the patient
has signed an authorization to release the information.
Medical records have other uses, too. For example,
they can be valuable for research, in creating quality
improvement (QI) programs, and for patient education.
Case Question
A
F
F
If you were Mary’s supervisor, how
would you approach Mary about this
situation?
216 Section III Administrative Medical Assistant Skills
Information from medical records also helps the government protect the public’s health as well as plan for
future health care needs.
Patients must authorize the release of any information from their medical record. See Figure 11-1, a sample release form.
Southern Arundel OBGYN
3008 Pryson Avenue, Severn, Maryland 21140
Privacy Official: Jessica Pyrtle, CMA
Telephone: 410-966-2100
Authorization for Use or Disclosure of Health Information
Patient Name: ________________________________________________________________________________________________________
Patient’s Date of Birth: ______________________________ Patient’s Identification/Chart No.: _______________________________________
I hereby authorize the use and disclosure of individually identifiable health information relating to me as described below:
Specific Description of the Information to be Used or Disclosed Including (If Practicable) the Dates of Service(s) Related to Such
Information: ________________________________________________________________________________________________________ _
____________________________________________________________________________________________________________________
The above information will be called “Authorized Information” throughout the rest of this form.
Persons or Class of Persons Authorized to Make the Use or Disclosure of Authorized Information:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Persons or Class of Persons to Whom the Use or Disclosure of Authorized Information May be Made:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Authorized Information will be used and/or disclosed for the following purposes:
[ ] At the request of the individual (check box if applicable)
[ ] Other (Please list each purpose of the use(s) or disclosure(s) in the space provided.):
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
s I understand that if the person or entity receiving Authorized Information is not a health plan or health care provider covered by federal privacy
regulations, the authorized information may be re-disclosed by the recipient and may no longer be protected by federal or state law.
s I understand that I may revoke this authorization at any time by notifying ____________________________ [NAME OF PRACTICE] in
writing. However, if I choose to do so, I understand that my revocation will not affect any actions taken by _______________________________
[NAME OF PRACTICE] before receiving my revocation.
s I understand that I may refuse to sign this authorization and that my refusal to sign in no way affects my treatment, payment, enrollment in a
health plan, or eligibility for benefits.
[ALTERNATIVE, IF APPLICABLE: I understand that ____________________________ [NAME OF PRACTICE] may require me to sign
an authorization prior to receiving research-related treatment or treatment solely for the purpose of creating health information for another
party and that ____________________________ [NAME OF PRACTICE] will not provide such research-related treatment unless I provide this
authorization. NOTE: If this provision is applicable, the third party for whom the information is being created must be listed under “Persons or
Class of Persons to Whom the Use or Disclosure of Authorized Information May be Made.” Also, the purpose for which the information is to be
created and disclosed must be listed under “Authorized Information will be Used or Disclosed for the Following Purposes.”
s [FOR MARKETING AUTHORIZATIONS ONLY, IF APPLICABLE] I understand that the person or entity I am authorizing to use and/or
disclose Authorized Information for marketing purposes may receive either direct or indirect compensation for doing so.
This authorization expires at the earlier of ____________________________ OR the date the following event occurs: ____________________
____________________________________________________________________________________________________________________
[describe event or write “not applicable”]
Signature of Patient or Patient’s Personal Representative: ___________________________________________ Date: _________
For Personal Representative of the Patient (if applicable): _________________________________________________________
Print Name of Personal Representative: _______________________________________________________________________
Describe Personal Representative Relationship/Authority to Act for the Individual (parent, guardian, etc.): __________________
____________________________________________________________________________________________________________________
[print or type]
Figure 11-1 A sample Notice of Privacy Practices required by HIPAA. (Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive Medical Assisting. 5th ed. Philadelphia, PA: Wolters Kluwer; 2016.)
Chapter 11 Medical Documentation 217
Medical Record Security
You will deal with medical records nearly every day—
documenting, adding lab reports and other items, and
so on. Patients’ charts must meet certain legal and ethical standards. So must your work with them. Access to
medical records must be limited. Only authorized individuals involved in the care of the patient should access
a patient’s record.
Case Questions
A
F
F
for family members to view records of other
family members? What would happen if he saw
records of other patients? Would this also be
a problem? How can the medical staff ensure
that patients and visitors do not have access
to the practice computers and patient medical records? If you were the medical assistant
in this situation, how would you approach the
patient when he was caught viewing the computer screen?
The information contained in your ofce medical
records must be:
Easy for appropriate individuals to retrieve
r
Organized
r
Accurate and complete
r
Secure
r
Security of medical records is a very serious matter.
You must have a system in place that insures that only
authorized individuals have access to a record. In addition, audits should be routinely performed to insure the
information being accessed is appropriate and necessary. Your ofce must offer a secure and private way for
individuals to le a compliancy complaint. These complaints must be investigated, documented, and resolved
as quickly as possible. Steps to prevent future issues
should be implemented to avoid additional compliancy
problems. Remember, just because you have access to
medical records, it doesn’t mean that you can access
records anytime you choose. Access must be limited
to only what is needed to provide proper care to the
patient. For example, accessing a friend or family member’s le for information (even if it is for them) is not
authorized use. Most ofces have policies that prohibit
employees from accessing records of family members or
friends in an effort to avoid such situations. Figure 11-2
shows two types of authorization forms for the release
of information.
Matthew McNeil, the patient from the
case study, was seen looking at his
wife’s medical record. Is it permissible
I, ___________________________________, give my
permission for _____________________________ to
release information generated in my medical record
between the dates of __________________________
and _________________ to _________________.
Signature __________________ Date ____________
Witness ____________________ Date ____________
Or
I, ___________________________________, give my
permission for _______________________ to release
information in my medical record regarding the care
and treatment of _____________________________
Signature __________________ Date ____________
Witness ____________________ Date ____________
Figure 11-2 A proper authorization for release of
information. (Reprinted from Kronenberger J, Ledbetter
J. Lippincott Williams & Wilkins’ Comprehensive Medical
Assisting. 5th ed. Philadelphia, PA: Wolters Kluwer; 2016.)
Information Found in the
MedicalRecord
A medical record contains two basic types of information:
1. Personal information includes the patient’s name,
address, telephone number, date of birth, social
security number, emergency contacts, employment,
and insurance. Many ofces also include a copy
of the patient’s health insurance card and photo
identier.
2. Clinical information is the information about the
patient’s health, medical conditions, and treatment.
The history and physical (H&P) portion of the chart
contains the following ve vital items for each ofce
evaluations:
Chief complaint (CC)—the patient’s explanation of
r
why he came to see the doctor, usually stated in the
patient’s own words, in quotation marks
History of present illness (HPI)—the patient’s com-
r
plaint stated in medical terms, with times and details
Medical history—includes family medical history
r
(FMH), a review of major illnesses of parents and
grandparents, aunts and uncles, and brothers and
sisters; past medical history (PMH), patient’s major
illnesses, surgeries, and hospitalizations; and social
218 Section III Administrative Medical Assistant Skills
history (SH), patient’s dietary habits as well as smoking, drinking, and drug habits
Review of systems (ROS)—an examination of the
r
body systems to look for problems not yet identied
Diagnosis or medical impression—the physician’s
r
opinion of the patient’s medical problems
Figure 11-3 is a sample of documentation and the
organized format used. This style makes the information easy to nd and identify.
Medical records are frequently divided into categories
as a means of organizing the information held within.
Views of an electronic medical record can frequently
be adjusted to accommodate individual or ofce preferences or needs. Views can include problem-oriented
medical records (POMR) and source-oriented medical
records (SOMR). Regardless of the view of the following, information will be held within a medical record:
Progress notes—a record of what happened each time
r
the patient was seen, including phone calls and prescription rells. The progress notes usually begin with
the patient’s H&P information.
Radiographic reports—reports of x-rays, CT scans,
r
MRIs, and similar studies that were done in the ofce
or at another facility.
Laboratory results—copies of the results of any tests
r
done at the ofce or at an outside facility. Examples
might include blood work and electrocardiographs
(EKGs).
Consultation reports—reports from other physicians
r
with whom the patient’s physician asked to consult
about the patient.
Medication administration—a record of the medi-
r
cines the patient was given or prescribed. Some ofces
use a separate sheet for any injections and other medication the patient received in the ofce.
All correspondence—copies of any letters or memos
r
the ofce sent about the patient, copies of any letters from the patient, and correspondence from other
physicians.
Jamie Williams
Miscellaneous—consent forms and the HIPAA pri-
r
vacy notice signed by the patient, as well as copies of any patient instructions regarding end-of-life
decisions. These might include organ donation
forms, a living will, and a power of attorney for
health care.
Secondary records—records received from another
r
physician, hospital, or other source. This information
is for review only and is not available for release from
your ofce.
Organization of Information within
Medical Records
There are two main organizational methods used for
medical records:
Problem-oriented medical record (POMR) organizes
r
information by the patient’s problem. This is a good
method for physicians who treat patients for a variety
of problems.
Source-oriented medical record (SOMR) les all
r
items according to their source. For example, all lab
reports are in one session of the record, and all radiology results are in another.
Whichever method your ofce uses, one thing doesn’t
change, the order. The most recent information always
appears rst in each section. In other words, most recent
ndings or events are on top or rst. This creates a
reverse order to the information. The farther back you
go in each section of a patient’s record, the older the
information is.
POMR Organization
Family practices, pediatricians, and others who treat a
variety of problems often use this method of organizing records. The patient’s medical problems are listed in
the rst section of the record. As each problem arises,
it is added to the list and given a number. All charting
about that problem elsewhere in the record is given the
same number. When the problem no longer exists, it is
recorded in the progress notes, and an X is marked next
to the problem on the problem list.
A POMR is divided into sections:
Figure 11-3 EMR entry sample.
1.
Database—the patient’s information, which includes
this information in the chart:
The patient’s chief complaint
r
The present illness
r
The patient’s medical history
r
Review of systems
r
Physical examination
r
Lab reports
r
2. Problem list—includes every past, present, and future
problem the patient has that requires evaluation.
3. Treatment plan—includes the workups, tests, and
treatment each problem has required.
Chapter 11 Medical Documentation 219
4. Progress notes—records of patient contacts that
are numbered and grouped together. Some physicians may prefer to group these notes to relate to
each numbered problem on the chart’s problem list.
Others might place them in chronological order.
SOMR Organization
Items in an SOMR are grouped by the type of service,
not by the problem to which they’re related. So, for
example, all the x-ray reports are led in one group,
with the most recent report rst, and so on.
Each ofce’s classication system may differ. But
the major groupings in an SOMR generally include the
following:
Progress notes
r
Lab results
r
Radiography reports
r
Patient education
r
This approach to organizing charts is the most common method used to organize records. It is most often
used by specialists as they tend treat a narrower range
of problems.
Patient Education
Regardless of the format of a patient’s record, it is
important that they have access and understand-
ing of the information contained within it. Many
practices are offering (and encouraging) patients’
access to their medical information through spe-
cial portals. This allows patients to view radiology
reports, laboratory results, and other information.
Keep in mind that this system does not give the
patient access to the entire medical record but
rather elements of the records. Additionally, many
of the systems allow patients to communicate with
their physician electronically using their portal
as well. To use their portal, the patient must rst
receive an access number granted by their medi-
cal ofce. Then, they can log into the system to
build an account with a password that they select.
Web portals are a great way for patients to access
information and communicate with your ofce.
Remember, when communicating using the por-
tal, all transmissions are condential and should
be treated as privileged communication. Take time
to insure that all communication is professionally
written and concise. If information seems com-
plex or has the potential of being misunderstood,
another means of communicating the informa-
tion, whether in person or by phone, should be
used.
C
O
G
The SOAP (subjective, objective, assessment, plan)
format is one of the most common methods of documenting patient visits. The SOAP format is made up
of four parts:
r
r
r
r
commonly used for documentation of patient care.
DOCUMENTATION AND
THE EMR
The subjective part is the direct statement or description from the patient telling about his or her own condition. These notes should show the patient’s exact
words using actual quotations. For example, “I’ve
been vomiting all night and have had diarrhea for the
past 2 days. The last thing I was able to eat was crackers at dinner time last night.”
The objective part includes information the medical
assistant and physician observe about the patient. It
can include test results and vital signs. For example,
“The patient appears weak, pale, and slightly dehydrated and has lost three pounds since her last visit.”
The assessment portion is the diagnosis made by the
physician.
The plan is a description of what should be done
including any necessary diagnostic tests, treatments
that will be given, and when the patient should follow
up with the physician, if at all. For example, “Stool
culture, CBC with diff, BRAT diet, and Imodium for
the next 48 hours. Call ofce if symptoms worsen;
return to ofce if patient not well by the end of the
week.”
Figure 11-4 shows a typical SOAP format, which is
Progress Notes
A chart’s progress notes record each contact with a
patient—whether by phone, mail, e-mail, or in person—
and briey summarize what happened. All notes are
electronically stamped with date, time, and signature of
person entering the information.
Medical History Forms
Medical ofces use these types of forms to get medical
and personal information from a new patient before
she sees the physician. Many ofces mail these forms to
patients before their rst appointment. The patient then
brings the completed form to the appointment. This process has several advantages:
The patient has time to think carefully about and
r
answer the questions.
The patient can gather information about the family
r
medical history.
The medical ofce receives a more accurate and com-
r
plete patient medical history.
220 Section III Administrative Medical Assistant Skills
Mamie Parrish
10/17/16
Pt. Called c/o fever, sore throat. Asked to speak to Dr. Johnson. Instructed
patient to come in for exam; explained that Dr. Johnson cannot treat her
over the phone. Given appt for tomorrow at 10:00 a.m.
10/18/16 Pt. called and stated that she felt "90% better". Appt. canceled.
Jennifer Wise, CMA
12/05/16 Office Visit
SUBJECTIVE:
OBJECTIVE:
ASSESSMENT:
Pt presents c/o of bad pain in R x 2 days.
Vital signs: T-101.3, P-94, R-16, BP-112/76. Urine pregnancy test
was done, negative. Urine dip was negative for blood and WBC,
pH 7.0, Urine was clear. Blood was sent to the laboratory for CBC
with diff.
Pain in R . Possible appendicitis vs. ovarian cyst.
PLAN:
Tylenol 650 mg suppository given now. Will await lab results and
notify patient with further instructions at that time.
James Owens, MD
C
O
G
MAINTAINING RECORDS
A huge amount of paperwork comes into the typical
medical ofce each day. This includes the following:
Radiology reports
r
Laboratory test results
r
Other test results
r
Hospital records
r
Notes from other physicians
r
Insurance information
r
All this material must be sorted and scanned into the
right patient’s chart. You will need to verify the patient
information and then scan documents not already
received electronically.
12/16/16 Lab work normal. Called pt. Per Dr. Johnson and instructed to notify us
if her fever is not gone tomorrow. Patient states, "I guess I feel some
better." Pt. will call office p.r.n.
Melissa Hurley, RMA
Figure 11-4 Sample SOAP notes. (Reprinted from
Kronenberger J, Ledbetter J. Lippincott Williams & Wilkins’
Comprehensive Medical Assisting. 5th ed. Philadelphia,
PA: Wolters Kluwer; 2016.)
In an EMR, the information from this form is keyed
or scanned into the patient’s chart. The completed form
is then shredded to protect the privacy of the patient’s
information.
Flow Sheets
A ow sheet is a form that allows information to be
recorded in a table or on a graph. An ofce may use
several types of ow sheets. They are generally designed
for a specic use, such as charting vital signs or tracking prescribed medications. They are also often color
coded. The graph on which to record a child’s height
and weight at each visit might be pink for girls and blue
for boys, for example.
Flow sheets are very useful forms to have in a record,
as described below:
Limit the need for long notes explaining the
r
information.
Eliminate the need to search through notes in the
r
record to nd the information.
Provide all the information at once. This makes it
r
easier to spot any changes over time.
C
O
G
WORKERS COMPENSATION
RECORDS
From time to time, a current patient will seek treatment
for an injury or illness he got on the job. These services
should be maintained in special area of the patient
record. In a workers’ compensation case, you must keep
separate medical and nancial records for the patient.
Workers’ compensation is health insurance that the law
requires employers to have for workers who suffer jobrelated injuries.
Unless the injury is life threatening, you must rst
have approval from the patient’s employer to treat the
patient and bill for workers’ compensation. (You’ll read
more about getting this approval in Chapter 14, Health
Insurance and Claims) Be sure to write the name of the
person who authorizes treatment in the patient’s medical record. Also chart any additional information you
receive that relates to the approval process. In workers’
compensation cases, the employer’s workers’ compensation insurer can review any information pertaining
to the injury or illness, even if the patient opposes it.
However, they are not entitled to any other information
within the patient’s record, only information directly
related to care resulting from the injury/illness.
C
O
G
MAKING ENTRIES IN
MEDICAL RECORDS
A patient’s medical record is a legal document. It can be
presented in court as evidence in a malpractice suit. The
entries the ofce staff makes in a chart can help win a
lawsuit—or prevent one altogether—if they are:
In an EMR, the software can create the ow sheet; all
you have to do is enter the information. The computer
automatically puts it on the graph or table.
Accurate and complete
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Clear enough to be read easily
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Timely, written at the time of the event
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