Documentation and ownership of health records
Documenting the patient’s history
When the medical assistant is responsible for documenting the patient’s history, care must be taken to ensure that the patient’s answers are not heard by others.
When privacy is available, the medical assistant may ask the patient questions and document the answers directly into the health record. This method offers an opportunity to become better acquainted with the patient while completing the necessary records and also ensures the patient understands what all the questions mean.
Collecting patient information
If new patients must complete a lengthy questionnaire, the questionnaire may be mailed to the patient with a request that it be completed and returned to the provider before the appointment. If the record is electronic the patient may access his or her record through a patient portal and document the information directly into the EHR system. It would then be reviewed by the medical assistant and provider during the office visit. Another option with an EHR is for the patient to complete a paper form and the medical assistant to enter the information into the EHR while reviewing the form with the patient.
Provider documentation
The medical assistant may document the patient’s chief complaint, but the provider will question the patient in more detail. Many practitioners write their own entries on the record in longhand if a paper record is used. Some may document the findings directly into the computer if an electronic record is used. Others may dictate the material, either directly to the medical assistant or by using a recording device.
If the material is dictated and transcribed, the provider should verify each entry and then initial the entry to verify its accuracy before it is entered into the patient’s record. The best indication of this is the provider’s signature or initials on the typed entry. In an EHR the provider’s electronic signature is proof of the accuracy of the entries.
Ownership of the health record
Who owns the health record? Patients often assume that because the information in the health record is about them, ownership of the record rightfully is theirs.
The patient has the right of access to the information within the record but does not own the physical record or other documents pertaining to the record. The patient has a vested interest and therefore has the right to demand confidentiality of all information placed in the record.
Protecting health records
The actual paper health record should never leave the medical facility where it originated. Even the provider should refrain from taking the record from the office to the hospital or nursing facility. If information from the record is needed, copies can be placed in a file, and progress notes can be written on site and inserted into the original record later.
This is not an issue with an EHR because the record can be accessed by multiple users at the same time. Patients’ paper records should be kept in a locked room or locked filing cabinets when the office is closed.
EHRs must be protected from unauthorized access.
Documentation standards
Written health records must be legible. Each record should be written as if the provider and staff expect it to eventually be involved in a lawsuit; therefore every word must be legible to an average reader years after it is written. The record can help the provider prove that he or she treated a patient in a competent manner, or it can prove that the patient was not given competent care. Every person on staff at the provider’s office is responsible for writing legibly in every health record.
EHRs eliminate the issue of legibility in the record, but it is just as important to be sure that all patient care is documented in the electronic record.