medical

• Accurate and efficient records management is essential in medical offices.
• Attitude is contagious and the source of information about all aspects of a patient's health care.
• A patient's medical record constitutes the legal record of the medical practice.
• Medical records generally include chart notes, history and physical, referral and consultation letters, medical reports, correspondence, clinical forms, and medication list.
• Policy may be affected by the physician’s office hours, which include the physician’s work speed, the treatment or procedure to be performed, the available office personnel and equipment, and the type of facility.
• The physician may have to make rounds of patients at one or more hospitals on certain days and at certain hours.
• The physician’s office hours may vary on different days.
• Before appointments can be made, the administrative medical assistant must know the basic schedule of the physician’s office.
• The main purpose of maintaining a medical record is to serve as the main source of information for coordinating and carrying out patient care among all providers involved with the patient.
• Another purpose of maintaining a medical record is to serve as evidence of the course of an illness and a record of the treatment being used.
• A medical record also serves as a record of the quality of care provided to patients.
• Planning the Call: Plan the conversation before making a call by gathering important papers, obtaining necessary information, and outlining questions to ask.
• A personal directory is used for phone numbers that are frequently called by the office staff and should be kept near the phone for easy access.
• When you have the proper information and are prepared to place a call, use the following procedures: Identify yourself and the physician’s office, state the reason for the call, provide necessary information, listen carefully and make notes as needed, and verify information.
• Maintaining a medical record ensures communication and continuity of care from one medical facility to another.
• A classified directory, or yellow pages, is a list of list telephone subscribers under headings for types of business such as “Office Supplies or Laboratories-Medical” and also contains advertising for subscribing businesses and sometimes contains local maps and ZIP Code listings.
• Know the specifics of the call before you dial: Ask yourself who, what, where, when, and why, and make appropriate notations.
• A telephone directory, or white pages, lists telephone customers by name in alphabetic order and often contains other information such as directory-assistance numbers, billing information, long-distance calling procedures, and area code maps.
• Be aware of the following: Whom to call and ask for once the phone is answered, what information to give or obtain, questions to ask, when to call, and possible situations that might arise during the call.
• The office adopts guidelines to protect the confidentiality of patients’ electronically transmitted medical data.
• If the person you are trying to reach is unavailable, leave a message for that person to call you back.
• E-mail must be subject to the strict privacy rules as other forms of communication.
• Other Directory Services available on the internet include AOL, NetFind, Switchboard.com, YellowPages.com, and B2B (Business to Business) Yellow Pages.
• Electronic voice mail operates in the same manner as voice mail, storing voice messages.
• Electronic mail, or e-mail, is a method of transmitting messages and files in the digital form from computer to computer.
• Numerous resources are available to the administrative medical assistant as aids in placing calls and in managing the flow of the calls in a medical office.
• A medical record serves as the legal record for the practice and as the main record to ensure appropriate reimbursement.
• A medical record serves as a source of data for research purposes.
• As a general rule, physicians have the right of ownership in the physical pieces of paper that constitute the patient records they develop in their office.
• Records management is the systematic control of records from their creation through maintenance to eventual storage or destruction.
• In a medical office, the three main types of records are patients medical record, practice management records, and correspondence related to health care.
• The two broad categories of filing are centralized, where files are kept in one place used by many people in the medical office, and decentralized, where information of use to only one staff member.
• AHIMA recommends retention schedules for patient health records, diagnostic images, and master patient index, register of deaths, register of surgical procedures.
• Filing equipment includes open-shelf files, filing cabinets, rotary circular file, vertical files, lateral files, and mobile-aisle files.
• When answering the telephone, try to visualize the person with whom you are talking, think about whom the caller is asking, how the caller feels, and whether he or she is a patient.
• The office policy should include a variety of other records related to the physician’s practice management, such as insurance policies, tax records, receipt for equipment, personal records and licenses.
• Almost all patients make their first contact with the physician by telephone.
• Micrographic records may be stored in card files or binders.
• The administrative medical assistant must learn to recognize the situation in each type of call and handle it correctly.
• Paper records can be stored through a process called micrographics in which miniaturized images of the records are created.