Medical Record

Medical records and Its Importance

Medical records have to be maintained regularly and accurately because patients’ treatment is planned accordingly and in turn, their health depends on that. Therefore, it becomes a medical assistant’s responsibility to maintain them in the proper way required so that patients receive adequate and correct treatment. The patients themselves understand their health condition thoroughly with their medical records. It helps healthcare industries further analyze diseases and the efficacy of the treatments provided and to come up with better treatments in the future.

In other words, medical records are important

  • For patients by way of helping them to understand their conditions and be healthy.
  • For physicians to provide correct and quality treatment
  • For research industries for analyses and medical research purposes.

Medical records must have

  • Clarity – Use of correct and accepted medical terminologies in the recording of patients’ diagnoses.
  • Completeness – Provide complete information with all forms duly filled.
  • Client’s words – Patients’ words should be recorded exactly and not be added or subtracted with the assistant’s ideas/views.
  • Chronological order – All the information should be according to the dates of its happenings from the first to the last so that it’s a map of understanding for physicians and patients.
  • Conciseness – All information should be accurate and to the point with the use of medical terms and abbreviations.
  • Confidentiality – Patient information should be safeguarded and kept confidential.

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