Another important aspect of the Medical Assistant's job is to create and maintain an efficient filing system, which requires an investment of time and effort. A well maintained filing system not only conveys a polished and professional image, but it also enables every medical assistant to effortlessly retrieve patient records and documentation whenever needed. Personal computers or computerized healthcare information systems are used in the performance of many of the above listed record-keeping tasks.
Every time health care personnel treat a patient, they record what they observed, and how the patient was treated medically. This record includes information the patient provides concerning their symptoms and medical history, the results of examinations, reports of x rays and laboratory tests, diagnoses, and treatment plans. Medical office assistants should always organize and evaluate these records for completeness and accuracy. Medical Assistants begin to assemble patients' health information by first making sure their initial medical charts are complete. Medical Assistants and all staff members must ensure all forms are completed and properly identified and signed, and all necessary information is in the computer.
The most common form of medical record documentation is commonly called the "SOAP" note. This is the medical documentation of patient presenting complaint and treatment. The note should be consistent, concise and comprehensive. Many medical offices use the SOAP note format to standardize medical evaluation entries made in clinical records. Most often SOAP notes are written by the physician, but with the correct training and supervision, a medical assistant can be asked to briefly interview the patient and enter the patient's reason for the visit under the "S" part, the "Subjective" line. As the medical assistant takes the patient's vital signs, this can be entered into the medical record under the "O", the "Objective" area to be reviewed minutes later by the physician. However, the medical assistant never writes the "Assessment" or the "Plan" but should be able to understand this vital part of the SOAP note.
So to review the "SOAP" note is the basic medical record of the patients visit to the office. S-O-A-P stands for SUBJECTIVE, OBJECTIVE, ASSESSMENT, and PLAN.
1. SUBJECTIVE—The initial portion of the SOAP note format consists of subjective observations. These are symptoms the patient verbally expresses to the medical assistant or by a significant other (family or friend). These subjective observations include the patient's descriptions of pain or discomfort, the presence of nausea or dizziness, and a multitude of other descriptions of dysfunction, discomfort, or an illness the patient describes.
2. OBJECTIVE—The next part of the format is the objective observation. These objective observations include symptoms that can actually be measured, seen, heard, touched, felt, or smelled. Included in objective observations are vital signs such as temperature, pulse, respiration, skin color, swelling and the results of diagnostic tests.
3. ASSESSMENT—Assessment follows the objective observations. Assessment is the diagnosis of the patient's condition. In some cases the diagnosis may be clear, such as a contusion. However, an assessment may not be clear and could include several diagnosis possibilities.
4. PLAN—The last part of the SOAP note is the plan. The plan may include laboratory and/or radiological tests ordered for the patient, medications ordered, treatments performed (e.g., minor surgery procedure), patient referrals (sending patient to a specialist), patient disposition (e.g., home care, bed rest, short-term, long-term disability, days excused from work, admission to hospital), patient directions and follow-up directions for the patient
Here is a rough example follows for a patient being reviewed following an appendectomy (removal of the appendix):
S: No Chest Pain or Shortness of Breath. "Feeling better today." Patient reports flatus.
O: [Vital signs, lab data, and physical exam results would be recorded here.]
A: Patient is a 37 year old man on post-operative day 2 for laparoscopic appendectomy, recently passed flatus.
P: Recovering well. Advance diet. Continue to monitor labs. Prepare for discharge home tomorrow morning.
Assignments:
1. Please read and study textbook pages 179-183
2. Complete study review questions after you finish next class on Basics Medical Law (Medical Records and Basic Law questions are combined after the class class).
3. Please view the videos below:
Copyright © 2024 Eastern Institute, Inc. (BVI) IBC. - All Rights Reserved.