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What should you use When indicating the exact words of a patient on a medical record?
Wiki User
∙ 10y ago
Quotation marks should be used when indicating a patient's exact words on a medical record.
Wiki User
∙ 10y ago
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If a code is not documented in medical records the medical assistant should never code a patient as having what?
a medical assistant should never code a patient as having what unless its is documented in medical record
The medical record should be released only with a?
Medical records are confidential. They should only be released after the patient has signed a release form.
When should a patient be advised of existence of computerized database containing medication information about the patient?
A patient has to sign a confidentiality agreement indicating whom may have access to the medical information and that is the main point. No one can legally have access to the patient information computerized or otherwise without express written consent from the patient.
What is the doctrine of proffessional discreation?
A physician may determine, based on his or her best judgment, if the patient with mental or emotional problems should view the medical record. Because the medical record is a written documentation of the contract established between the physician or healthcare provider and the patient, it must be retained for legal purposes.
How should an insurance billing specialist correct an error on a patient's record?
elctronic health record how should an error be corrected on a patient
What parts of medical record should be checked to see whether additional forms need to be added before a patient arrives for an office visit?
appointment
Why a medical assistant should adapt to a patient's individual needs?
A medical assistant should always adapt to a patient's individual needs. This is because the patient is the one that needs help and cannot adapt to the medical assistant.
Why should the medical assistant glance over the progress notes from the last visit before a patient arrives for his or her appointment with the physician?
to make certain that results from ordered laboratory tests are in the medical record.
Why should medical assistant glance over the progress notes from the last visit before a patient arrives for his or her appointment with the physician?
to make certain that results from ordered laboratory tests are in the medical record.
What do i do as a medical assistant if a patient faints?
A medical assistant can help a patient who is fainting by helping the patient get to a seated position. This lessens the risk of injury to the patient from falling. The medical assistant should then instruct the patient to lower his or her head below the knees. This promotes blood flow to the brain. The patient should then be instructed by the medical assistant to breathe slowly and deliberately. In the meantime, the medical assistant should seek further assistance from a physician or other healthcare professional. The source of the patient's fainting (syncope) should be obtained.
What actions should be taken if you identify an error in a patients medical record?
No deletions should be made, as the medical record is also a legal document. But an amending notation should be made and added to the medical record.
Why should a recording in the medical record never be erased or abliterated?
The medical record is a legal document.
