Lesson 2 — Communication in the Clinical Setting

Accurate documentation is one of the clinical medical assistant's primary responsibilities. It is said that if something is not documented, it did not happen. Accuracy in documentation is one of the most important responsibilities of a medical assistant. This is critical in both paper and electronic health records, or E-H-R.

Even though paper records are less common, there are general guidelines that apply to both paper-based and electronic records. The medical assistant should always confirm the patient's name and date of birth, or D-O-B. They should also ensure accuracy of spelling, abbreviations, and terminology when documenting a patient's symptoms. Once complete, the M-A should date, sign or initial, and review all entries for accuracy.

It is the medical assistant's moral and ethical duty to ensure complete privacy of patient records. Medical records should be completed in a private and quiet location to ensure patient confidentiality. Access to and changes in medical records are on a need-to-know basis. This means that only those working directly with the patient should be accessing the records. M-As must be diligent to protect patient records. If using paper records, charts should only be left in a secure location. If the chart is visible, the M-A should cover the patient's information with a blank sheet of paper. This may occur if a paper chart is placed in a slot at the back or side of an exam room door. When utilizing the E-H-R, the M-A must never share their login or password information. The M-A is responsible for all entries made with their username and password. Similarly, the M-A must be sure to close the patient's record and log out of the E-H-R before leaving the exam room.

Because medical records are legal documents, medical assistants should never scribble, erase, or use Wite-Out if an error is made in a paper-based record. Instead, they should draw a single line through the entry that they wish to correct. Next, they should write the word, "error" above the mistake, being sure to initial and date it. If an entry needs to be corrected or updated, the M-A can create an addendum by putting additional information below the original entry. This is also true if additional information is to be added after the record is complete. Since medical documents are permanent records, a medical assistant would never use pencil in a paper chart. Instead, black, or blue permanent ink is used. An M-A should also make sure no blank spaces or lines are left, as this creates an opportunity for someone to change or add to the original entry. There are specific guidelines when completing paper charts. The date is formatted as month, day, and then year. If the medical assistant is documenting in standard time, a.m. or p.m. must be included. If military time is used, the M-A would enter the time in four-digit format, as with fourteen hundred. For example, an office using military time would denote two p.m. as fourteen hundred.

When utilizing electronic health records, the patient's information is added directly to the record. This happens during the patient interview. Depending on the E-H-R utilized, there are often drop-down menus, pop-ups, and alerts to assist in collecting necessary data within the patient record. Free text boxes are available to add additional documentation. All entries should be proofread before saving the record. The E-H-R automatically tracks the name and credentials of the person logged into the records. If an error is made, the M-A should follow the facility guidelines on how to indicate an error in the patient's record. The M-A should also follow the facility's guidelines for creating an addendum to the record.

Clinical medical assistants will most commonly document patient care in electronic health records. Electronic health records are the go-to method for patient medical record management. E-H-Rs reduce medical error since all providers can access the patient's clinical notes, treatment plans, prescriptions, and more. In addition to patient records, E-H-Rs include e-prescribing and formularies, patient portals, and tools for clinical decision support and practice management. They track clinical quality measures to provide data and insight for improved patient outcomes and satisfaction.

There are many notable capabilities of E-H-R systems. For specialty practices, unique software can be designed to match medical terms respective of the specialty. The scheduler provides automated reminders, appointment confirmation, and referral management. Prescriptions can be submitted directly to the pharmacy. Lab requisitions can be completed, ordered, and filed with the appropriate laboratory. All systems are easily integrated and utilized during telehealth appointments. Clinical medical assistants and the entire healthcare team benefit from practice management features within the E-H-R. The E-H-R system provides paperless records, including patient medical history and treatment plans. Providers may utilize templates that require similar information and create consistency among notes. P-H-I is more secure under digital lock and key.

Providers with E-H-R systems utilize e-Prescribing and have access to formularies. The E-H-R system offers prescribers a guide to prescription choice. Formularies help them choose cost-effective drugs, which increases patient compliance and overall satisfaction.

The "HI-TECH" Act was passed to encourage providers to use E-H-R systems. The act provides financial incentives for meaningful use of E-H-R technology. This includes tools like e-prescribing, electronic exchange of health information, and reporting on clinical quality measures. Providers who chose not to implement E-H-R may see a decrease in payments from Medicare and Medicaid.

The clinical medical assistant may field questions from the E-H-R patient portal. The portal allows patients to communicate directly with their providers to request prescription refills or ask questions. Due to the ease of connecting with a provider through the portal, patient engagement increases. Patients can also easily complete or update forms and schedule appointments.

The E-H-R system also helps manage the financial aspects of healthcare. The medical billing system interfaces with clearinghouses for electronic claim submission and tracks insurance reimbursement. The charge capture function stores diagnosis codes using International Classification of Diseases, or I-C-D, and procedure codes using the Current Procedural Terminology, or C-P-T. Insurance eligibility can also be verified.

E-H-R systems collect the data required to assess clinical quality measures, or C-Q-M. C-Q-M provide a snapshot of the processes, experiences, and outcomes of patient care. The data collection allows statistical review and reporting of population health data. These data points are evaluated to determine safe, effective, patient-centered, and equitable care. Reporting C-Q-M is part of the incentivized programs for meaningful use of E-H-R technology.

The E-H-R allows each team member to do their part while improving workday flow. Multiple users have access to a patient's record at the same time. The clinical medical assistant may be updating a note in the chart while the front desk assistant is scheduling in the same record. The insurance coordinator may also be submitting a claim for the same patient.

The "HIP-AA" Security Rule enacted regulatory guidelines to ensure safe storage and retention of patient protected health information, or P-H-I. The clinical medical assistant may be responsible to assist in backing up files. This daily occurrence may be done automatically or completed using an external hard drive, backup server, or on an online backup system.

Providers can find clinical decision support through the E-H-R features. The system provides information and preventive care considerations for medical conditions. Physicians can conduct additional research in a database. Because multiple providers can access and contribute to the patient record, patients receive more comprehensive care.