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If a code is not documented in medical records the medical assistant should never code a patient as having what?
Wiki User
∙ 6y ago
a medical assistant should never code a patient as having what unless its is documented in medical record
Wiki User
∙ 6y ago
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What is medical records?
Medical records can easily be used interchangeably with Health records. These records systematically document a patient's history, from medical to demographic. These records are so detailed that they give you a complete analysis of what is patient's current illness, what is his current medication, what were his past medication and illness details etc. Healthcare providers are responsible for maintaining these records for their patients. Conventionally all the medical records were documented on paper. However, with the advent of Electronic Medical Records these records are now documented electronically using computers. Some established electronic medical records also provide cloud technology, which ensures safety, accuracy, and accountability of medical records.
If a receptionist sends check up reminder for patient to someone other than patient is that considered patient-doctor confidentiality?
Which of the following might constitute breach of patient-doctor confidentiality? A. Medical assistant phones patient to convey test results B. Medical assistant looks at patient's medical records C. Receptionist with no medical training makes appointment for patient D. Receptionist sends checkup reminder for patient to someone other than patient
Can the spouse of the patient see his or her medical records?
A spouse can look at the patient's medical records only with the express consent of the patient.
Who maintains patient records?
The Medical Records Department prepares and maintains patient records.
Who owns patient medical records?
The doctor and the patient.
Who owns a patient's medical records?
The doctor and the patient.
What are two types of patients records?
Two types of patient records are electronic health records (EHRs), which are digital versions of patient charts, and paper-based medical records, which are physical documents containing patient information and medical history.
If a medical assistant looks at a patient's medical records are they breaching patient doctor confidentiality?
Actually patient-provider confidentiality is not breached if a medial assistant looks in a patients' chart. Medical assistant's are considered providers of healthcare also. It is reasonable to understand that the medical assistant and even the nurse will access your chart if their is a need to. Upon triage the medical assistant will triage and note their findings accordingly in your chart as required by law. The medical assistant may also need to access your chart for the purpose of obtaing an authorization for medication or even diagnostic procedures as ordered by a physician. It is required by law that you sign a "consent for treament" before medical services are provided. Contained within that consent it will clearly state "My doctor or designee". A medical assistant is a "designee" of the physician to perform these tasks. The Privacy Act of 1974 and the HIPAA Act of 1996 are the guidelines to live by in patient-provider confidentiality. Doctor-patient confidentiality means exactly that; anyone viewing the records besides the doctor or the patient without permission constitutes a breach. There are some exceptions but these tend to occur in a hospital setting, or a mental institution. Even then, other staff participating in treatment will typically keep their own records as necessary.
Who organizes and codes patient records?
A: Medical Records Technician
Are medical records confidential?
yes medical records are confidential due to the sake of the patient's privacy
What does expired patient means in medical records?
It means patient died
Are electronic medical records available to the public?
No, electronic medical records are not available to the public. Anyone's medical records are completely confidential and restricted to the doctor and patient unless other permissions are given by the patient. Patient Portal is a product offered by CureMD with the EMR which is actually for the patients and doctors to check and maintain medical records from anywhere.
