Summarize a list of at least three protocols that should be followed when charting in a paper medical record. Explain why these protocols should be followed
What will be an ideal response?
ANSWER:
It is very important to follow protocol when charting in a paper medical record. Blue or black ink only should be used to enter information. Red ink may be used to indicate allergies, however all other colors of ink should be avoided. Handwriting should be legible, small and neat so it is easy to read. It is important that anyone looking at the record can read what is written. When correcting an error, a single line should be drawn through the error. The proper information should then be entered and the medical assistant should date and initial the errors. Food and drink should be avoided in the area in which documentation is performed. Personal opinions, comments, and defaming remarks are never to be included in a medical record. Doing so is considered unprofessional. Also, it is outside the scope of practice for a medical assistant to diagnose, therefore, no assumptions regarding a possible diagnosis should be entered.
You might also like to view...
Normal QRS interval is ________ seconds or less than three small blocks
Fill in the blank(s) with correct word
Which law is created by the courts via judicial decision and can be changed by the courts (it contains notions of common sense and precedent)?
A) Constitutional B) Statutory C) Common D) Administrative E) None of the above