Copyright Goodheart-Willcox Co., Inc.
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Unit 1 Health Informatics Career Pathway
• Present illness or current complaint requires a clear description of
the patient’s current signs and symptoms.
• Responsible party means the person who will be in charge of
payment for the healthcare services the patient receives.
All written forms become part of the patient’s medical record. This
record communicates information about the patient’s medical status to
healthcare workers. It is also a legal document that provides evidence
of the care the patient has received. In addition, medical records can be
used for research, public health initiatives, or patient education. Because
they are critical to patient care, these records must be easy to locate, well
organized, accurate, and complete, but also brief.
Often called the patient’s chart or fi le, each medical record contains
two types of information—personal and clinical. Personal information,
which may be included in a registration form, tells the doctor’s offi ce
personnel how to contact a patient. It usually includes a photocopy of the
patient’s insurance card. Clinical information begins with the patient’s
medical history and includes all of the information about his or her
health, medical conditions, and treatment (Figure 2.11). The personal and
clinical information are separated in a patient’s chart.
Remember that protected health information (PHI) must remain
confi dential. All written fi les must be protected from unauthorized access.
You cannot leave fi les in areas where others may see them.
When a new patient makes an appointment, a medical clinic or
offi ce will often send forms for the patient to complete and bring to the
appointment. This is more effi cient than having the patient fi ll out forms
while waiting to see the doctor. The patient has time to gather information
and think carefully about the questions at home. As a result, the medical
offi ce receives a more accurate and complete medical history.
Many medical offi ces maintain a website where patients can
download and print these forms or establish a private account and
complete them online. If the offi ce uses electronic health records, all
handwritten forms are scanned into the patient’s chart, and the paper
forms are shredded to protect the privacy of the patient.
In addition to personal information and a medical history, the
offi ce needs permission to bill an insurance company. The offi ce also
needs permission to share confi dential information with any other
individual chosen by the patient. The offi ce must give every patient a
notice of privacy practices that explains how his or her protected health
information is kept confi dential and under what circumstances the
information can be released to others.
Maintaining Accuracy: Kia
Kia makes sure that patient information is complete and
clarifies any handwriting that is difficult to read. Using a private
area to consult with patients, or making sure others can’t hear the
discussion is a legal requirement. Kia double-checks the
forms for all required signatures so that bills for service
can be sent to the insurance company. Accurate
registration avoids future problems.