Importance of Health Records

Posted by Winnie Melda on November 19th, 2018

 Introduction

            Health records also referred to as medical records are some of the most important health database requirements for both the patient and the medical assistant while doing her job. A consistent recording by the medical assistant while doing their jobs is proof that they are helping the doctors, nurses, and other medical staff to monitor properly patient health, medical planning, and treatment. Initially, medical staff would use health records in describing individual medical processes. However, modern health records have become broader than they used to be, and they are not recorded and helpful to the doctors only but also to the medical assistants. Health records are increasingly being used as the basis for the individual to realize their rights in both legal and civil transactions.

Importance of Health Records to Medical Assistants

            Records may be referred to as information and documents stored systematically, scientifically, and in a way that it will be easy and helpful to receive the required data and information whenever necessary. In a similar way, medical records is a systematic method of storing required data, information, and all the relevant medical documents with the goal of availing them easily when it becomes necessary. Such records include patient name, age, gender, occupation, illness, diagnosis, and the recommendations made by the doctor in the course of treatment. As much as they help the patient acquire the right treatment, medical records act as a tool for the medical assistant looking into the patient as asserted by Peissig et al., (2012).

            Medical assistants are among the staff and clinicians in the hospitals. Medical records help in clinical decision support. Therefore, they provide the medical assistant under whose care patients’ health is with knowledge and patient-specific information. The medical records provide intelligently filtered and appropriately presented information at suitable times. This helps the medical assistants to enhance patients’ health and health care. Furthermore, medical records comprise computerized alerts and reminders to the medical assistants who are at the heart of patients’ health. They also encompass clinical guidelines, patient data reports, and condition-focused order sets. Others are medical summaries, documentation templates, and medical diagnostic support. The combination of these helps the medical assistant in better decision making which they pass to the doctors according to Vuk et al., (2015).

            We cannot undermine the relationship between a medical assistant and the patient. Therefore, medical records appropriately act as the sole means through which medical assistants obtain and provide necessary data in connection with the health of the patient. Additionally, medical assistants provide data of the brunt of the specific illnesses at the specific places within the healthcare to the healthcare sectors as well as the nation although it has to be referred to the doctor or other medical stakeholders. On the same note, properly managed medical records help the medical assistance in obtaining ways through which they can render their services to the healthcare, standard of service, diagnosis pattern, and methods of treatment. They also help the medical assistant in managerial functioning according to the healthcare institution.

            Medical records are instrumental and critical for the medical assistants to understand patient concentration, nature of the illness, and all the personal details of the patient on behalf of the doctor. Good arrangement of the medical records helps in easy retrieval and access of the invaluable facts and figures. Therefore, a medical assistant can make some modifications in the existing plans and policies and help the healthcare institution in formulating some additional policies in the event of urgency and other directives thereby delivering better and standardized medical services to the patients in the future and probably many years to come.

            According to Miriovsky et al., (2012) health records help in documenting historical examination, diagnosis, and treatment of the patient. The health information records keep important for the medical assistant and other medical providers involved in the patient care and for other subsequent providers including a medical assistant who take responsibility for the patient. In disciplinary and peer review matters, health records can help medical assistants justify or refute the need for a particular treatment on behalf of the doctor. In cases of reimbursement and utilization disputes between medical assistants and other healthcare providers, health records can help in documenting what services were rendered and whether they were necessary. Health records also serve as evidence for the medical assistant whenever there is a malpractice claim or other inquiry regarding the patient care.

Conclusion

            The paper has discussed the importance of health records to a medical assistant during their work. There are other importances besides what the paper has discussed which are also important to other healthcare providers. However, for medical assistants to realize the above general importance of health records while doing their work there is a need for vigilance thereby ensuring high standards in keeping the records regardless of whether the records were written or recorded electronically. Medical assistants should also make the most use of the health records while doing their work.

 References

Miriovsky, B. J., Shulman, L. N., & Abernethy, A. P. (2012). Importance of health information    technology, electronic health records, and continuously aggregating data to comparative           effectiveness research and learning health care. Journal of Clinical Oncology, 30(34), 4243-4248.

Peissig, P. L., Rasmussen, L. V., Berg, R. L., Linneman, J. G., McCarty, C. A., Waudby, C., ... &  Carrell, D. (2012). Importance of multi-modal approaches to effectively identify cataract        cases from electronic health records. Journal of the American Medical Informatics           Association, 19(2), 225-234.

Vuk, J., Anders, M. E., Mercado, C. C., Kennedy, R. L., Casella, J., & Steelman, S. C. (2015).     Impact of simulation training on self-efficacy of outpatient health care providers to use          electronic health records.International journal of medical informatics, 84(6), 423-429.

 Sherry Roberts is the author of this paper. A senior editor at MeldaResearch.Com in research paper writing help 24 hours if you need a similar paper you can place your order for essay writing services.