Nursing

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medical Assistant Roles - On Maintaining Medical records and Consent

One of the managerial functions of a medical assistant is maintaining medical records of the patient under the care of the medical establishment or medical practitioner he or she is working with. Being able to maintain and file documents in an methodical fashion is one of the many things that medical assistants must learn to master.

The medical assistant must prepare the records and keep them filed in so that when the medical practitioner looks at the record he will easily see the things he needs to see. In this manner the doctor can check the record and see what medicine he or she is currently giving his or her patients, what tests had been done and the lab results needed in diagnosing the patient. As soon as the medical practitioner is done seeing and assessing the patient, he will record his new findings in the medical record. The medical assistant will see to it that the medical record will be put back to the filling cabinet. This way, the record is safe and secured. lose pages must be secured and those who use the record must never tamper on the results.

Part of this role is ensuring who has rightful access to the record. The patient upon request can have a copy of his or her medical record. In case that the patient is unable to make personal decisions like a comatose patient, kids of legalized age, brother or sister of legal age, nearest relative or legal guardian may access the medical record. In an emergency and the patient is unconscious the medical people can access the medical record. Meanwhile, medical records of children can be access by parents or their legal guardians. Also, researchers can access the record as long they got permission and there is a written record that the identity of the client will not be disclosed. Authorities can also access the medical records of the patient but they can never change base on the medical record alone.

As a specific role of medical assistants, they should see to it that the record is kept and signed by the legal bodies. However, before obtaining approval of the patient, ther patient must be well informed of any risks involved with the medical practice. The benefit and the side effect of it if any, other options and what happens if the patient will not have it. For some reasons complains and in some cases goes to judicial.

Medical record and consent are two legalized documents in the health care business. It must be well protected.

Medical record documents all procedures and treatments done to the patient from the initial assessment to the current prognosis. It contains the diagnostics and assessments made by the medical practitioner of the person’s physical, emotional and mental wellbeing. The person’s pattern and way of living is also recorded and kept in file. Unlawful access to it is a violation of the person privacy.

The second record is known as the consent. It is giving consent for the medical practitioner to conduct medical procedure, surgery, therapy and others that require under the law consent. This record is very important. It can protect the medical practitioner from complaint of medical negligence.

Medical assistant truly needs to understand these two records because they are regularly used in the hospital. This task may seem effortless but it is not. To keep these records secure, the medical assistant must possess high level of decency and devotion in the job.

Medical assistant jobs and training. Visit the links to discover what is a medical assistant and learn if this career suits you best.
What makes a great nursing assistant?

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