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Step-by-Step Guide to Medical Record Keeping

Learn the procedures, steps, risks, and requirements for medical record keeping.

Stethoscope draped over a laptop

Medical records management is one of the most crucial components of ensuring a patient receives the best treatment possible. Once a patient record has been created, it must be properly stored and maintained each and every time they visit a medical professional. These records must also be properly destroyed after they’ve been retained for the appropriate amount of time. There are various regulations when it comes to the management of medical records, and if they are mismanaged, patient privacy can be put at risk.

As you can see, medical record keeping is an essential practice in the healthcare field. This fundamental skill may not sound like an exciting prospect for new healthcare professionals, but it is a vital task they will need to learn.  In fact, many Medical Assistants are trained to fulfill medical record-keeping tasks in various environments.

This article provides an in-depth guide on the art and science of medical record-keeping, one of the most important healthcare procedures for medical staff.

(Click here to see our full list of the most common Medical Assisting duties and responsibilities).

Medical Record Keeping Definition

What Does It Mean to Perform Medical Record Keeping?

Medical records create a permanent account of a patient’s medical history. Their accuracy is vital for effective communication between patients and healthcare professionals. Medical records help ensure that each patient’s needs are correctly assessed and met. These records may include information on illnesses, medical conditions, lab results, immunizations, screenings, biographical data, and documentation of services. In the present day, most medical records are digitally stored, allowing them to be easily accessed in electronic databases.

What is the Purpose of Medical Record Keeping?

The goal of medical record keeping is to help ensure that your patients receive quality care at the right time. In addition, proper documentation is vital to protect yourself and your employer. It can potentially save you from liability, fraud, or abuse claims. It’s also essential to the survival of any medical practice.

How Long Does it Take to Perform Medical Record Keeping?

It’s important to remember that medical record keeping is an ongoing process and consists of many steps that can take anywhere from days to months to complete. In many states, the medical records of a patient are likely kept for five to ten years after their last treatment.

Who Can Perform Medical Record Keeping?

While several healthcare professionals may be qualified to keep medical records,  it’s typically a task that’s reserved for Medical Office Administrators (MOAs). MOAs are multi-competent health professionals who play a crucial role in the organization and management of data in a medical office. They are also referred to as medical records and health information technicians. Medical Office Administrators utilize several systems to code and categorize patient information for databases, registries, and other purposes.

(Click here to learn how to become a Medical Office Administrator).

Depending on the medical setting, Medical Assistants may be tasked with medical record keeping as part of their administrative role. These MAs have the ability to respond to a patient’s inquiries or concerns, schedule physician appointments, and update patients on released medical results.

(Click here to learn how to become a Medical Assistant).

Training Requirements for Medical Record Keeping

Requirements for medical record keeping can vary and depend on your location or profession. Aspiring healthcare professionals will usually receive this training through their educational programs. For instance, most aspiring MOAs in the U.S. will require a postsecondary certificate. Some employers may require an associate degree as well. Formal training may generally take anywhere from nine months to two years to complete.

At Unitek College, we offer a Medical Assisting program that could give you a strong advantage in the field or when applying to healthcare positions. Our courses include topics like medical office administration, medical law, pharmacology, diagnostic imaging, professional conduct, and more.

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Medical Record Keeping Procedure

Medical Record Keeping Steps

With these steps, you can start to learn more about the process of medical record keeping. Of course, like most skills, medical record keeping requires time and practice to get it right. Remember to follow your facility’s rules and ask for help whenever necessary.

Here are some of the general guidelines that healthcare professionals should follow when performing medical record-keeping tasks:

  1. Check to ensure that the organization only allows authorized staff access to patient medical records.
  2. Consider medical considerations to help you decide how long to keep a patient’s records. For instance, if another physician sees a patient for the first time, they may want to review immunization records or significant health events.
  3. Ensure medical records are available:
    • Whenever requested by the patient or their authorized representative
    • To the physician or succeeding physician if the physician discontinues their practice
    • As required by law
  4. Do not refuse to transfer medical records that are requested by the patient or their authorized representative.
  5. Charge a fair fee (if required) to transfer the record.
  6. Store medical records that have not been transferred to the patient’s current physician.
  7. Inform the patient on how they can access their stored records, the amount of time they will be available, etc.
  8. Verify that discarded medical records are appropriately destroyed to protect the patient’s confidentiality.

Necessary Equipment for Medical Record Keeping

Typically, the suggested supplies for medical record keeping include but are not limited to the following items:

  • A reliable computer
  • Fax machine
  • Printer
  • Scanner
  • Phone

Potential Risks or Complications of Medical Record Keeping

According to a study by Johns Hopkins, medical errors are one of the highest leading causes of death in the United States. Furthermore, poor management of medical records may lead to medication errors, treatment discrepancies, and missed diagnoses. Mismanagement puts patient privacy at risk. It can also leave providers vulnerable to lawsuits, fines, and even criminal charges.

This highlights the necessity of well-trained medical record keepers who can correctly fill their roles in the management of medical records. If you think about it, the well-being of the patient, provider, and healthcare system all depend on the effectiveness of medical record-keeping staff.

The word tips in wooden letter blocks

Pro Tips for Mastering the Art of Medical Record Keeping

Here are some tips that may assist you in the future.

  • Create Medical Record Keeping Procedures. In order to properly manage medical records, an organization needs to first outline its policies for security maintenance. According to HIPAA requirements, these policies must be written, and the documents must be preserved for six years. Keep in mind that some organizational changes require updates to record maintenance. Additionally, successful records management usually requires engagement from the entire organization.
  • Implement Thorough Employee Training. Some security breaches are caused by untrained employees who mismanage sensitive information. To remedy this—and follow HIPAA guidelines—your organization must educate any employee who interacts with medical records throughout the data lifecycle.
  • Label Records Correctly. Before you can effectively monitor and manage medical records, your organization must develop an indexing system that includes every type of record they handle. This will help make data searching more efficient, which can save both time and money.
  • Consider Automating Processes. It can be daunting to stay in compliance with state and federal laws. This is where automated processes can really save the day. So, looking into automating the most crucial or time-consuming ones. A management program for medical records can lead to improved accuracy, consistency, and protection.
  • Increase Data Security. This might just be the most important tip of all. While it probably goes without saying, security is everything when it comes to medical record management. All your electronic records should have a comprehensive audit trail. In addition, paper records need to be in a secure, locked room. Offsite records need to be placed in certified facilities that ensure proper climate and storage. Lastly, medical records at the end of their lifecycle should only be destroyed through NAID-certified methods.

Why Should Medical Assistants Learn How to Perform Medical Record Keeping Tasks?

It is very beneficial for Medical Assistants to learn how to perform medical record-keeping tasks. This is because medical records management is a key component in maintaining the overall health of each provider, patient, and system. Thanks to MAs and other medical record keepers, physicians can maximize their time with each patient and better serve the public.

While medical record keeping isn’t always a job requirement, Medical Assistants are often responsible for at least some tasks in this realm. It’s a simple yet valuable skill that can lead to more significant opportunities. Therefore, it would be advantageous for MAs or aspiring Medical Assistants to pursue the proper training. Once they are ready to perform medical record-keeping tasks, an MA could become more indispensable to their employer and possibly gain greater responsibilities.

Medical students in a hallway

Start Your Career in Medical Assisting

The ability to perform medical record-keeping tasks is a crucial skill that aspiring Medical Assistants should learn for their careers. It’s also an important practice for the survival of most healthcare providers, such as physicians, hospitals, clinics, and other medical systems.

Think about it: Medical record keeping plays a key role in maintaining patient safety, privacy, and treatment. By assisting physicians throughout this process, Medical Assistants can help respond to a patient’s inquiries, schedule physician appointments, and update patients on released medical results.

If you’re feeling inspired and want to pursue a career in medicine, Unitek College offers various healthcare programs, such as our Medical Assisting program.

Contact us today to learn more about our programs and tuition assistance options. Take the first step toward a rewarding future in healthcare!