How To Organize And Maintain Medical Records And Consent

One of the managerial functions of a medical assistant is maintaining medical records of the patient under the care of the medical institution or medical practitioner he or she is working with. Learning how to keep and maintain medical record is one of the requirements for licensing and or certification.

The medical assistant must prepare the records and keep them filed in so that when the medical practitioner looks at the record he will easily see the things he needs to see. In other words, it is easier and more organized if the medical assistant knows how to file the documents well. As soon as the medical practitioner is done seeing and assessing the patient, he will record his new findings in the medical record. The medical assistant will see to it that the medical record will be put back to the filling cabinet. This way, the record is safe and secured. Losing any page, unauthorized accessing and tampering ought to be avoided at all times.

The medical assistant must know by heart the ones who have rightful access to the medical records of the patients. The patient upon request can have a copy of his or her medical record. In case that the patient is unable to make personal decisions like a comatose patient, kids of legalized age, brother or sister of legal age, nearest relative or legal guardian may access the medical record. In an emergency and the client is unconscious the medical people can access the medical record. Meanwhile, medical records of children can be access by parents or their legal guardians. Medical researchers can access the medical record if the research that they are doing is relevant to the sickness of the patient but without disclosure of the identity of the patient. Authorities can also access the medical records of the patient but they can never chage base on the medical record alone.


As a specific role of medical assistants, they should see to it that the record is kept and signed by the legal bodies. Nonetheless, prior to obtaining consent of the client, ther patient must be well informed of any risks involved with the medical procedure. The benefit and the side effect of it if any, other options and what happens if the patient will not have it. For some reasons complains and in some cases goes to court.

The medical record and the medical consent of the patient are two legal records that must be well secured.

The first is the record of the patient, going back from the first time the patient went to see the medical practitioner for consultation or medical support. It contains the diagnostics and assessments made by the medical practitioner of the person’s physical, emotional and mental health. The person’s pattern and way of living is also recorded and kept in file. Unlawful access to it is a violation of the person privacy.

The second record is known as the consent. It is giving commendation to the whole medical procedure, treatment and operation. This record is very important. It can protect the medical practitioner from complaint of medical malpractice.

The medical assistant must have a very good knowledge about these two records in order for him or her to totally protect and maintain the security and decency of these records. It may seem easy but it is not. To keep these records secure, the medical assistant must possess high level of decency and devotion in the job.

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