Question

The medical assistant is catching up on the completeness of the practice's medical records. She notices that the provider wants a transcript of two telephone calls that had not been previously recorded. She now records them, post dates when the calls were made, and signs the entry.Is this acceptable? Discuss(explain)A well0 informed client discusses her marital problems with the provider and says, "Please do not put this in my record."How would you handle this? (explain)

Answer 1

Record maintainace are very important and to be done timely. Any compromise in it can lead to problems in the future. In this case the provider needs a transcript of earlier conversation, the medical assistant has recorded the call and clearly mentions the date ,time and signs it.Which is legally acceptable as the records are genuine and done as per the request of the provider.

The provider has to comply with the HIPAA ,if the provider rationalizes the need of documenting the information provided by the patient then it is unavoidable to be mentioned in the records.This is possible if the current conditions cause is because of the marital life and needs the information for future treatment ,in that case it will be mentioned in the records. The provider has to mention about this to the patient. In case of hiding these types of things it can alter or affect the treatment regimen.