Abstract In this paper I will be discussing the influences that take part in a medical assistant’s decisions on a daily basis. The research includes three different situations where the medical assistant was influenced by laws and regulations and the release of patients personal and medical information. I will also be discussing the relevant components of a patient’s medical record, and what a physician looks for in it. There will be an overview of all the documentation that would be in these components. The first situation where the actions of a medical assistant were influenced by laws and regulations is a patient’s wife came into the office requesting the results of her husband’s STD results. She claims that he gave her permission to seek these results for him. The medical assistant tells her; unfortunately it is against the law for me to disclose any of your husband’s information with you, even if you say you have his consent. It would breach my AAMA code of ethics as well as the HIPAA law.
The medical assistant states that if your husband would like to bring you along on his next visit, when he gets his results that would be fine. Other than that there is not much she can do for the patient’s wife. Another situation would be pertaining to minors. Many teenage minors seek birth control without their parent’s consent. They may go to a local clinic or even their family physician. Well a mother of a young teenage girl came into the office and wanted to speak to the doctor regarding her daughter’s last visit.
She was asking the medical assistant if her daughter was sexually active, and if she had received birth control. The medical assistant explained to her that she wasn’t allowed to give her that information. The mother stated well my daughter is only 14 years old and is considered a minor, and it is my business to know these things about her. The medical assistant responded that it would be a breach of patient confidentiality even if she was a minor to give that information out. The medical assistant explained to her that even though she is a minor she still has her rights as a patient.
The only way to find out what was said and what was given to her, was to sit down and speak to the daughter. The last situation regarding actions of a medical assistant being influenced by laws and regulations pertaining to the information of a patient would be speaking about a patient’s medical information in front of another patient. This would break the HIPAA law and the AAMA code of ethics. Professional medical employees should only speak about a patient in a disclosed area, where no one else could hear them. They should also only be talking about medical information, not personal information regarding a patient.
One medical assistant heard two others in the office discussing a patients pregnancy test results as well as other tests at the counter where patients were walking by to get into their rooms. It wasn’t that the information was bad, but it should not have been discussed out in the open. The medical assistant went to an office manager and explained the situation, and how it breached the patient’s rights of confidentiality. Medical and family history should also be some of the first documents in the file. This helps the physician know some more in depth information about the patient.
This includes if a patient has any allergies, medical issues now or in the past, as well as if the patient complains of something they can look back on the family history to see if there is any connection for a diagnosis. If the patient has any allergies what so ever they should be on the cover of the file on a bright sticker labeled allergies. The patient’s medical record should also include HIPAA paperwork that has been read over and signed by the patient and medical assistant. The patient should also receive a copy of this form as well as a patients’ rights pamphlet.
This covers the office from law suits and allows the office to submit all medical bills for all services and procedures rendered by the office. Contact information is also important information that should be in the records. If there is an emergency the office must know whom to call or get in touch with in these circumstances. There should also be a copy of a health care proxy on file. Things happen when we least expect it. You wouldn’t want your neighbor making life altering decisions on your behalf, because the office has no information on who to contact.
All lab work should be documented in these records as well. Physician’s need to keep updated records on a patient’s CBC’s, blood sugar, thyroid, etc… on a yearly basis and monitors them. Any pregnancy information will also be documented in this record. Whether a person has had natural births, cesarean section, miscarriages, etc… Physicians also keep notes in these records for every visit. They document everything that is done, said, meds given, diagnosis, reason for visit, etc… These notes are very important, not only for the patient, but for the doctor.
These notes can be looked back on in case of law suits, accidents, or a misdiagnosis of some kind. In conclusion a medical record is a very important detailed source of a patient’s personal and medical information. A person can find and maintain a person’s medical diagnosis, due to their history and past medical history. This can be helpful and useful information, something life threatening come about. A medical assistant must always make sure to identify if a patient has some kind of allergy by placing a bright colored sticker on the file cover.
By doing this you may be saving a patient’s life, or from sustaining a serious allergic reaction to medication, insect bites, etc… ? References Cox-Stevens, K. , Marshall, J. R. (2004). Being a Medical Clerical Worker: An Introductory Core Text, Third Edition. [Online version]. Retrieved from AIU Online Virtual Campus. Medical Office Procedures: HLTH221-1003B:02 website. http://www. ncbi. nlm. nih. gov/pmc/articles/PMC2082070/ retrieved August 7, 2010 http://www. gvsu. edu/pas/index. cfm? id=E19C1A28-E93E-DC87-2FA78E8344E9769D retrieved August 6, 2010