Accurate and timely documentation is one of the key responsibilities of medical assistants. They are in contact with people of all ages, backgrounds, and health conditions while providing care. Whether electronically or in print, the recording of a patient's condition, treatment and response to treatment, provides the crucial information needed by each members of the patient’s healthcare team, and is the legal record of the care provided.

This two-part series provides medical assistants with an understanding of the importance of accurate and objective charting in order to assist the patient's continuing care and of the legal and administrative considerations related to healthcare documentation.

Overview

This program will examine some of these legal and administrative functions of documentation, including complying with the federal patient privacy requirements found in HIPAA.

After completing this course, the learner should be able to: