HP 215C – Medical Assisting Medical Records Discussion – University of Arkansas

A patient’s medical records are a recording of information that documents facts and events during the administration of patient care—it contains sensitive, personal information and tells a story starting with the patient’s medical history, current assessment, lab and other diagnostics, diagnosis, treatment plans, medications, interdisciplinary documentation, and includes all medical complaints as well.

Expand on the importance of maintaining medical records (paper and electronic) and filing purposes.

Include the following aspects in the discussion:

• Provide in detail at least two measures currently being used to maximize accuracy and completeness of the patient medical record.
• Explore the consequences of having inaccurate and incomplete patient records in any medical setting.
• Discuss what specific efforts you would make to ensure the two measures you outlined above are met by the medical staff in your charge if you were an office manager.