Your Guide to Mastering Medical Record Keeping

Medical records are the foundation of patient healthcare and proper management of those details ensures that they receive the best possible treatment. Your role as a medical office assistant is crucial to the accurate, efficient, and confidential flow of that patient’s information. During your medical office courses/medical assistant training program, you will learn the details of medical record keeping and management, but reviewing the expectations allows for you to know precisely what you’re in for and if this career is a fit for you.

Your Step-by-Step Guide to Mastering Medical Record Keeping

What is record keeping and what is expected of you in your role in medical office administration?

• Medical records are an account of a patient’s medical history. Accuracy is critical as they provide the foundation for effective communication between all members of the healthcare team and help to ensure proper assessment and care. They can include information on conditions, lab results and treatments received. They are most often digitally stored for access across various healthcare databases.
• In keeping accurate records, you not only influence patient care but protect you and your employer as well, helping to ward off any claims of liability, abuse, or fraud.
• Consistent and ongoing upkeep of records in accordance with Canadian law and guidelines is essential. So, understanding those protocols are key to your success.

How long must you retain a medical record?

The Canadian Medical Protective Association (CMPA), an organization dedicated to supporting physicians, patients, and the healthcare system, governed by a council of physicians, recommends retaining medical records for 10 years, 16 in BC.

Who has access to records?

These are the details outlined by the CMPA:

• The physical medical records are the property of the physician.
• A patient is entitled to examine and receive a copy of the complete medical records compiled by the physician in administering advice or treatment to the patient, including records prepared by other doctors that the physician may have received.
• The patient is not entitled to examine or receive copies of any information or material received or compiled by the doctor outside of the physician-patient relationship.
• A patient’s general right of access to medical records is not absolute. The court stated that patients should have access to the medical records in all but a few circumstances. The physician may use discretion not to disclose information the physician reasonably believes is likely to cause a substantial adverse effect on the physical, mental, or emotional health of the patient or harm to another person.
• A patient should have access to the medical record unless there are compelling reasons to not disclose. The onus is on the physician to justify denying access.

Since this decision, many jurisdictions have enacted privacy legislation that governs the collection, use, and disclosure of personal health information.

As a general rule, information about a patient should be disclosed only in one of the following scenarios:

• on the written authority of the patient
• on the written authority of the patient’s authorized legal representative
• on receipt of a court order compelling disclosure
• when the request comes from an agency or individual expressly entitled by legislation to a copy of the records.

How must you secure a medical record?

Medical records are required to be properly protected and secured, in either their physical or electronic form. Paper records must be kept in an area that has restricted access, or in locked cabinets. In electronic form, they must be protected by security features and access controls, accessible only to those in the patient’s circle of care.

How do you store and dispose of a medical record?

• It is your responsibility to ensure records are stored in a place that is secure and safe, in so far as you have been given that responsibility by your employer, or in keeping with the guidelines they set out. Whether onsite or offsite in a storage facility, healthcare professionals must store records in accordance with applicable Canadian privacy legislation and College of Physicians and Surgeons (College) requirements, based on province.
• Specific obligations are based on the College requirements, based on provincial or territorial legislation, and privacy legislation. As a general rule, destruction should ensure that the record cannot be reconstructed, and maintains privacy, such as shredding or pulverizing the document. It is also recommended by the CMPA that a list of names of the patients whose records are destroyed be kept permanently in a secure location for reference.

How do you transfer a record?

• As patients change doctors or a new member of the healthcare team is added there may be a request for patient records to be shared. A medical record originating from the office you work in, is considered the property of that office. As such, it is recommended that original files stay with that office. A physical may therefore provide another means of relaying the patient information, by preparing a letter or report summarizing the pertinent details or a copy of the file may be provided if specifically requested. In all cases you must maintain confidentiality, and always be aware of privacy legislation and College policies and guidelines.

While there are many intricate details when it comes to maintaining and processing patient medical records, this gives you an idea of the scope of your potential responsibility. As you pursue your medical administrative assistant diploma at a medical assistant college you will dive into the specifics and what all of this essential work entails to ensure you enter the workplace skilled and confident. As a MOA, in addition to helping physicians and medical teams navigate this process, you will respond to patient inquiries, schedule appointments and update those medical records – essential and rewarding work indeed.

If you’re detail oriented and want to make a difference every day in the role you play in healthcare, this may be the career for you. You can start your Medical Office Administration career right away, or if you’re still wondering if it’s the right fit, take the “Anderson College Medical Office Admin Career Training Readiness Quiz”.

Either way, we have a team dedicated to ensuring you have the support you need … from determining the right program fit, understanding whether you’re eligible for financial assistance, to program completion and preparing to land that dream job.

Book a virtual appointment with one of our Admissions Advisors and let’s get you on your way, shall we?

Quick Links to Fuel Your Success!

We want to make sure you have what you need to succeed! Check out these reference links:

• Medical Office Administrator Courses & Programs at Anderson College
• Patient Confidentiality and YOU – For Medical Office Admin Graduates
• 5 Skills to Give you the Leading Edge as a Medical Office Admin (andersoncollege.com)
• Canadian Medical Protective Association