Medical Record

The patient medical record, also referred to as the patient’s “chart” or “file,” is the source of information
about all aspects of a patient’s health care. Accurate and up-to-date medical records are vital to a medical
practice. Current records are necessary for enabling a continuum of care for patients, for financial and
legal success, and for research purposes. It is not surprising, therefore, that one of the most important
skills an administrative medical assistant can demonstrate is the ability to maintain accurate and complete
medical records.
A patient’s medical record holds all data about the patient. Medical records generally include the
following items:
• Chart Notes. A chronological record of ongoing patient care and progress. Chart notes are
entries made by the physician, nurse, or other health care professional regarding pertinent points
of a given visit or communication with the patient. The chart notes for a new patient may be
extensive, often containing the details of a medical and physical history.
• History and Physical (HP). History refers to the patient’s complete medical history (usually
obtained by the physician during an interview with the patient on his/her first visit); physical
refers to the initial results of a physical examination by the physician.
• Referral and consultation letters. Copies of letter sent to other physicians, referring the patient
for
• Medical Reports. Lab reports, x-ray reports, and reports from special procedures such as
electrocardiograms are kept in the medical record.
• Correspondence. Copies of all correspondence with the patient, including letters, faxes, and
notes of telephone conversations and e-mail messages are part of medical record.
• Clinical Forms. Forms such as immunization records and pediatric growth and development
records are included.
• Medication List. A listing of all medications prescribed, including dosage, dispensing
instructions, as well as a list of the patient’s known allergies to medications, if any, are in the
medical record. In addition to medical data, the patient’s record contains administrative data, such
as the patient’s personal information, including insurance and billing records, and release of
information and assignment of benefits.

Medical Records as Legal Documents

A patient’s medical record constitutes the legal record of the medical practice. On occasion, patient’s
records may have to be produced in court, either to uphold the rights of the physician if the physician is
involved in litigation or to substantiate the claim of the patient if the physician is called as a witness. In
malpractice cases, the content and quality of a medical record can be pivotal, leaving a greater impression
on a jury, and even in the physician’s credentials, personality, or reputation. If the data in a medical
record are incomplete, illegible, or poorly maintained, a plaintiff’s attorney may be able to make even the
best patient care appear negligent. Therefore, it is important for the administrative medical assistant to
help the physician maintain medical records as carefully as possible. The assistant should bear in mind
that any record could become a vehicle for defending a clinical course of action down the road.
Reasons for Maintaining Medical Record
Medical records provide the practice with complete information regarding the patient. Thus, they are used
by the practice in the following ways:
• As the main source of information for coordinating and carrying out patient care among all
providers involved with the patient.
• As evidence of the course of an illness and a record of the treatment being used.
• As a record of the quality of care provided to patients.
• As a tool for ensuring communication and continuity of care from one medical facility to
another.
• As the legal record for the practice.
• As the main record to ensure appropriate reimbursement.
• As a source of data for research purposes.
Because the medical record is the basis for so many activities in a practice, every effort should be made to
maintain it well. Each time the patient is seen by a provider, such as for blood pressure check-up or a
special procedure, or on a return visit for a medication, whether in the office or at another location, an
entry or notation must be made in the patient’s medical record. Entries must be keyed or handwritten.
Remember that no part of a record should be altered, removed, deleted, or destroyed. Only proper
correction procedures may be used. Great care must be taken when entering data to ensure that they are
inserted in the correct chart. If an error or discrepancy is discovered in the medical record at a much later
date, the physician may dictate an addendum to the record to correct the discrepancy.
Ownership
The medical notes made by the physician, the actual chart notes, reports and other materials are the
physician’s property. The notes are for the physician’s use in the treatment of patient. However, the
physician cannot use or withhold the information in the record according to his or her own wishes. It is
understood that even though the notes made by the physician are the physician’s property, the information
in the record, the nature of the patient’s diagnosis and so on, belongs to the patient. For this reason,
patients have the right to control the amount of type of information that is released from their medical
record. Furthermore, patients alone hold the authority to release information to anyone not directly
involved in the care.
Records Management
Records management is the systematic control of records from their creation through maintenance to
eventual storage or destruction. Recorded in any form whether in a computer file, in a paper document, or
stored on disks is considered a record. In medical offices, the three main types of records are:
1. Patient medical records. The central responsibility of the physician’s practice is patient care. For this
reason, the proper handling of the patient medical record is critical. This record is also known as the
patient “file” or “chart,” contains chart notes, all medical and laboratory reports, and all correspondence
about the patient.
2. Correspondence related to health care : includes general correspondence about the operation of the
business, orders for medical supplies, research reports, journals, newsletters and announcements from
professional organizations.
3. Practice management records. Business and financial management of the practice must also be
carefully kept. These documents include insurance policies, income and expense reports, copies of tax
returns for the practice, financial statements, etc. Also kept are copies of managed care contracts and the
office’s compliance program and privacy policy. Personnel and payroll records are also part of practice
management.
The two broad categories of filing are: (1) centralized – files are kept in one place used by many people in
the medical office. (2) decentralized – information of use to only one staff member, such as physician’s
correspondence, is stored in a decentralized file convenient to the user.
Filing Equipment
The kinds of filing equipment and supplies that best suit a medical office depend on how records are used
and who needs to use them.
• Open-shelf files – are bookcase-type shelves that hold files
• Filing cabinets
• Rotary Circular File
• Vertical Files
• Lateral Files
• Mobile-Aisle Files

Filing Supplies
The important considerations in choosing filing supplies are durability of material and uses of color and
positioning within a file to make the user’s task easier.
• Folders – may be purchased in various colors, styles and tab cuts. Tabs are the projections that
extend beyond the rest of the folder and can be labelled and easily viewed. Tab cuts refers to the
position of the tab. Folders are filed in such a way that tab cuts with the accompanying labels are
read in an orderly fashion from left to right.
• Labels - Oblong pieces of paper, frequently self-adhesive
• Guides - are rigid dividers placed at the end of a section of files to indicate where a new section
or category of files begin, they support folders and are visual clues to the user of the file, showing
exactly where in the file drawer new main subjects begin.
• Out Guides - is a card placed as a substitute for a file folder that serves to indicate that a folder
has been removed from the file. The front of the out guide has lines to record the name of the
person who is taking the file, the date the file was removed, and the material contained in the file.
When the file is returned, these annotations are crossed out and the out guide may be reused.
Everyone always knows where a particular file may be found.
 • Cross-Reference Sheets – is prepared to indicate where the original material is filed and where
in the files other copies may be found. The cross-reference sheet may be in a different color from
the file folders to make identification simpler. Steps in Filing Following logical, consistent,
systematic steps in preparing materials for filing enables the assistant to file accurately, to find
materials quickly, and to refile documents efficiently.
The steps in filing are:
Step 1. Inspecting documents
The assistant is responsible for inspecting the documents. Inspect if the document is in good
physical condition, and the information should be complete. Check the attachment and if action should be
taken. The document must also bear a release mark. Releasing is the indication, by initial or by some
other agreed-upon mark, that the document has been inspected and acted upon and is ready for filing.
Step 2. Indexing
One the document has been released and is ready to be indexed. Indexing is the mental processing
of selecting the name, title, or classification under which an item will be filed and arranging the units of
the title or name in the proper order. Selecting the proper classification for an item is critical to finding
the document when it is needed.
Step 3. Coding
It is the placing of a number, letter, or underscore beneath a word to indicate where the document
should be filed. For example, in the correspondence of Jose Gomez, the name Gomez would be
underscored or coded. The code may be written on the document, usually in the upper-right hand corner.
Step 4. Sorting
The assistant working with a number of items prepares them for the file by sorting them or
arranging them in the order in which they will be filed. Before they can be sorted, documents must be
indexed and coded.
Step 5. Storing
It is the actual placement of an item in its correct place in the file. When the item is placed in the
folder, the top of the item should be to the left. Documents are placed in the folder with the most current
document on top. The folder is then placed in the file cabinet with the tab side to the rear of the file.
Reminders and Follow-up Procedures
This special file used for follow-up actions is called tickler file. Many items have been stored may require
some further action to be taken. For example, Mr. Gomez may require a reminder to return for his annual
checkup. An arrangement of index cards by months of the year and, within each month, by days of the
month is practical. Notations of actions to be taken are placed on cards behind specific dates of the
month.
Another way to be reminded of a follow-up action is to use a colored index tab clipped to a patient’s
record. The colored tab indicates that some kind of action is required. Different colors may be assigned to
stand for different kind of actions.
There are also electronic monthly calendars available in most software application suites. If actions to be
taken are entered on specific dates of the electronic calendar, the software will provide an automatic
tickler, a message on the screen, on the appropriate date. The assistant may find this system more efficient
and easier to use.

Filing Systems
Effective records management requires records to be filed in the way they will accessed. Several filing
systems are sued. Most offices actually use more than one filing system to organize their different types
of information. The major filing systems are alphabetic, numeric, and subject. Each system has features
that are advantages, as well as certain disadvantages.
1. Alphabetic Filing. In alphabetic filing, names, titles, or classifications are arranged in alphabetic
order. The assistant must consider each word segment a unit and must alphabetize unit by unit,
comparing letter by letter within the unit. All punctuation marks are to be ignored and the rule of
filing “nothing before something” is followed.

Advantages of alphabetic filing are that (a) because it is based on symbols with which most
people are familiar and (b) a misfiled document is easily found.

Disadvantages of alphabetic filing are that (a) it does not protect confidentiality because its
symbol are so easy to read and (b) it offers limited filing space and makes expanding system
difficult.

2. Numeric Filing. It is a system in which each patient is assigned a number and the numeric value
is cross-indexed to match the number with the name. Numeric filing may either be straight
number, using ascending numbers in systematic order, or terminal-digit, using the last digit, or
last set of digits, as the indexing unit.

3. Subject Filing. It is the placement of related material alphabetically by subject categories.

Color-coding
Color-coding is used in many medical offices. In a colored-coded system, color folders are used for
patients’ files to help identify categories visually. Different colors stand for various letters of the alphabet
or for numbers. For example, to organize the file of patient medical records, red folders may be used to
file the letters A through D; yellow to file E through H; green to file I through N; blue for O, P, and Q,
and purple for the letters R through Z.
Locating Missing Files
Even in a well-organized office, paper documents will occasionally be lost or misfiled. Here are a number
of suggestions for locating missing file.
• Look directly behind and in front of where the item should be filed.
• Look between other files in the area.
• Look in the bottom of the file drawer and under the file folders if they are suspended.
 • Check for the transposition of first and last names, for example, Wheng, Hart instead of Hart,
Wheng.
• Check alternate spellings of the name, for example Thomasen and Thomason.
• In numeric filing system, check for transposed numbers, for example, 19-63-01 instead of19-01-
63.
• In a subject filing system, check related subject files or the Miscellaneous files.
• With the permission of those who have used the file recently, search the desk or work area of
previous users of the file.
• Check with other office personnel.

Retention of Records
Process of maintaining and disposing of records.
Every medical practice has files from previous years and all types of information. For example, patient
medical records include files for patients who are currently being treated by the physician, those who
have not seen the physician for some time, and those who are no longer patients for one reason or another.
For management purposes, these files are classified as:
• Active files, pertaining to current patients.
• Inactive files, related to patients who have not seen the physician for six months or longer.
• Closed files, containing the files of those patients who have died, moved away, or terminated
their relationship with the physician.
Each office sets the criteria and time frames for placing files in one of the categories. This policy is part
of a larger policy for record retention – the length of time records must be retained and the proper
disposition of them when they should no longer be stored. Record retention policies project physicians
from exposure to risk and legal problems.
American Health Information Management Association: 1991 – Present
AHIMA is the leading voice and authority in health information, wherever it is found. AHIMA-certified
professionals ensure that sensitive health stories remain accurate, accessible, protected, and complete at
all times.
The following time frames have been recommended by AHIMA as retention schedules, subject to local
laws and regulations:
• Patient health records (adults): Ten years after patient’s most recent encounter.
• Patient health records (minors): Age of majority plus statute of limitations on malpractice.
• Diagnostic images (such as x-rays): Five years.
• Master patient index, register of births, register of deaths, register of surgical procedures:
Permanently
Philippine Records Management Association, Inc. or PRMA, Inc. is a professional organization that
specializes in the sharing of knowledge about records and information management at the national and
international levels.
The office policy should include a variety of other records related to the physician’s practice
management:
• Insurance policies: Current policies are kept in safe storage in an accessible file. Professional
liability policies are kept permanently.
• Tax Records: Tax records for the three latest years are kept in a readily accessible file. The
remaining records may be kept in a less accessible storage area.
• Receipts for equipment. Receipts for both medical and office equipment are kept until the
various pieces of equipment are fully depreciated, that is, until the value of the equipment has
completely diminished.
• Personal records and licenses. Professional licenses and certificates are kept permanently in safe
storage. Banking records such as statements and deposit slips are kept in the file for three years.
They may then be moved to a storage area. Other personal records, such as noncurrent
partnership agreements, property records, or other business agreements, are also kept
permanently in a storage area.
Paper versus Electronic Records
To save space, paper records can be stored through a process called micrographics in which miniaturized
images of the records are created. These images are usually in a microfiche (sheet of film holding 90
images) or ultrafiche (compacted film holding up to 1000 images) format and are viewed on readers that
enlarge the images. Micrographic records may be stored in card files or binders. With the increased use of
the large memory capacity afforded by computers, paper records may also be scanned, and stored records
must be kept according to the same retention schedule as paper records.
Disposition of Records
Records that have been closed or those that must be kept permanently, patient records, personal records,
and business records may be transferred and are said to be in dead storage, a storage area separate from
the area where active files are kept. Dead storage need not be easily accessible and can be in a location
other than the office.
There are financial and storage considerations for every practice. All records cannot be kept indefinitely.
Some states have laws related to the destruction of records and even specify the method of destruction.
General guidelines provided by AHIMA includes:
• Appropriate ways to destroy records include burning, shredding, and pulping. Records must be
destroyed so that there is no possibility of reconstructing them.
• When destroying computerized data, overwriting data or reformatting the disk should be done.
Other methods delete file names but do not really destroy data. Microfilm, microfiche, and laser
disks may be destroyed by pulverizing.
 Telephone Techniques and Procedures in a Medical Office
Telephone calls may be incoming, outgoing, or interoffice. Since administrative medical assistants
typically handle all incoming calls to medical offices, they should use each call as an opportunity to
present a positive image for the physician and the practice. An assistant must:
• Follow proper telephone etiquette (conduct).
• Screen calls according to the office’s policy.
• Take complete and accurate messages.
Telephone Etiquette
When answering the telephone, try to visualize the person with whom you are talking. Think about who
the caller is, what the caller is asking, how the caller feels, and whether he or she is a patient. If you do
this, your voice will sound alert, interested, and concerned during the conversation.
Use a pleasant tone that conveys self-assurance to the caller along with a genuine desire to be
understanding and helpful. This is what is meant by the phrase using a “voice with a smile.”
Use variations in pitch and phrasing to avoid sounding monotonous, and never indicate impatience or
annoyance through the sound of your voice. When speaking into the telephone, hold the mouthpiece
about an inch from your mouth to avoid distortion or faintness of voice. Speak clearly and do not run
words together or mumble. Even if you answer the phone with the same greeting many times a day, say
the words slowly enough for the caller to understand. Always speak at a moderate pace throughout the
conversation, giving the caller time to think about and understand what you have said.
When concluding a conversation, say “Good-bye” and use the caller’s name. This will leave the caller
with a pleasant impression. Finally replace the receiver gently when you hang up.
Promptness. Courtesy begins with promptness in answering the call. The ideal time to answer a call is on
the second ring. This allows the caller a moment of preparation time to begin the conversation (the caller
will expect to hear at least one ring before there is an answer).
Greeting and identifying. There are many ways to answer the telephone, but the preferred method is to
answer with the name of the physician or clinic followed by the assistant’s name. Answering with “Good
morning” or good afternoon” adds a personal touch but may be inefficient in a busy office. It may be
more important to take the time to say the name of the office slowly and distinctly. If the physician has a
common surname, the physician’s full name may be used to avoid confusion.
In large clinics, the person who is operating a switchboard may answer the call by
identifying the name of the clinic and asking how the call should be directed. After a call
has been transferred, employees in individual departments will then identify themselves.
Following are some other tips to remember as part of proper telephone etiquette:
• Identify the nature of the call, so that it can be properly handled. For example, calls may be
categorized as routine versus emergency.
 • Uses courteous phrases such as please and thank you.
• Listen carefully.
• Use words appropriate to the situation but avoid using technical words.
• Offer assistance as necessary.
• Avoid unnecessarily long conversations.
• Avoid using colloquial or slang expressions such as you know, ain’t and uh-huh.
• Conclude calls properly by saying “Good-bye” and using the caller’s name. If necessary, repeat
information at the close of the call.

Screening Calls
Most incoming calls concern matters that can be handled by an administrative medical assistant guided by
the preferences of the physician. Some physicians may prefer to speak to patients no matter what the
circumstances. However, this routine is likely to be inefficient because it can cause interruptions to the
patients who are being seen at that time by the physician. Also, medical records are probably not available
for the physician’s reference at the time of the call. In some offices, a nurse is available to answer
patients’ questions. Other offices have a policy that nonemergency calls are returned by the physician
during preset hours, such as after 4 p.m.
Screening calls, or evaluating calls to decide on the appropriate action, is often a difficult problem for the
beginner, who may be afraid to assume the responsibility of making decisions. It is important to discuss
this aspect of the job with the physician at the very beginning and to ascertain to what extent the
administrative medical assistant will handle calls alone, what information should be given out, when
messages should be taken, and when to tell the patient that the physician or nurse will return the call. A
call screening sheet, such as the one shown in here, can be used to assist you in screening and transferring
calls.
The administrative medical assistant must be guided by the physician’s wishes in deciding whether to
handle a call or to transfer it to the physician. The first priority is to determine the nature of the call. You
will then have a good idea of how to handle the call.
Message-Taking Situations. Many calls can be handled by taking a message. Examples of such calls
include the following:
• An ill new patient wants to talk with the physician about treatment.
• A patient already under treatment wants to talk with the physician.
• A patient’s relative requests information about the patient.
• A personal friend or relative of the physician calls for the physician.
• Attorneys, financial planners, hospital personnel, and so on call about business.
• A patient calls with a satisfactory or unsatisfactory progress report.
• Lab or x-ray results are called in.
 • Prescription refills are requested. The following calls are usually put through to the physician:
• Calls from other physicians.
• Emergency calls, for example, calls from the intensive care unit or the emergency room of the
hospital.
• Calls from patients the physician has already identified (for example, out-of-town patients, the
family of a seriously ill patient calling to check on the patient’s condition, or a patient in labor).
• Calls from a patient with an acute illness, such as seer reaction to a medication.
If there is a nurse in the office, many of these calls can be routed to the nurse, who will then decide
whether to interrupt the physician in an examination room.
Emergency Calls. An emergency call may come at any time. The person who telephones may probably
be upset, and people who are excited often forget to give the most important information. It is imperative
that the assistant remain calm and handle the call efficiently, reassuring the caller that help will come as
quickly as possible. The importance of obtaining the name, address and telephone number of the patient
cannot be emphasized too strongly. The more information you can obtain, the better.
A physician who is in the office when an emergency call comes through will speak with the patient.
However, the person answering the phone should screen the call to determine if it is urgent. Great tact and
excellent judgement are needed to do this. These qualities are developed through training by the physician
in what is a real emergency as the practice defines it and how to handle the calls.
Nonmedical Screening Situation. One of the most difficult situations to handle over the telephone is the
person who refuses to state the purpose of the call, saying that it is a “personal call” or a “personal
matter”. A person friend does not hesitate to state that fact. Similarly, a legitimate caller will give a name
and state the reason for the call. The administrative medical assistant may explain that the physician will
not return the call unless the nature of the call is known, if the physician has given such instructions. If
the caller absolutely refuses to give information, it is permissible to suggest that a letter be written and
marked “Personal” so that the physician can become acquainted with the matter and give a response. A
confident, pleasant voice will help you make the physician’s position clear while avoiding needless
disputes.

Taking Messages
Because most calls cannot be taken immediately by a medical staff member, the assistant must take care
of the messages so that the telephone calls can be returned later.
Remember the following procedures for taking efficient, informative telephone messages:
• Always have pencil and paper on hand.
• Make notes as information is being given.
• Ask politely to have important information repeated.
• Verify information such as names, spellings, numbers, and dates for accuracy. You might ask
“Would you spell that prescription’s name, please?” or “Let me repeat that to be sure I have noted
it correctly.”
 • Make inquiries tactfully. A tactful question might be “Will Gary know what this is about?” or
“Could I tell Sue what this is about?” or “Is this a medical matter? If so, the physician will need
your medical record.”
The more information you include in the message, the better, Be brief, yet thorough. When taking a phone
message, do not say “I will have the physician call you.” This makes a commitment on behalf of the
physician. It is better to say” I will give the message to the physician” or “I will ask the physician to call
you.”
After taking message regarding a patient’s care, the assistant should obtain the patient’s chart. The
telephone message should be attached to the chart with a paper clip and place to the message center for
the nurse or the physician. The message slip, or the transcription of it, as well as the physician’s or the
nurse’s actions, will be permanently documented in the patient’s medical record.
Message Slips. Printed telephone message slips are available from the stationaries for writing down
messages efficiently and fully. See example below of a message slip. Telephone message slips have
blanks for noting basic information about the phone call, such as date, time, to and from information, and
the subject of the call. In some office, the computer system is used to enter and send messages to the
physician.
Verifying Information. When you are taking messages, it is a good idea to repeat important details, such
as the date and time of an appointment or a telephone number. Verifying information reassures both
parties of the call, if you are not sure of the correct spelling of a name, say “I’m sorry. Will you spell your
name again, please?” or “I want to get your name correctly. Will you please repeat that?”
Answering Service
Physician’s offices often use commercial answering services or answering machines for phone coverage
when the office is closed. Commercial answering for phone coverage when the physician’s office to
answer the office’s calls from a remote location. All unanswered calls are forwarded to an operator during
non-office hours. This operator takes messages for routine calls or contacts the physician if the call is an
important emergency. The physician or the administrative medical assistant checks in with the answering
service for any message after returning to the office. An answering machine connected to the office
telephone line plays a prerecord messages to the caller. It tells the caller what to do when the call is urgent
or routine. The message can be changed according to the circumstance. Remember that the answering
machine needs to be turned off when the staff is in the office. Customized Telephone Message Slip
Outgoing Calls
In addition to answering calls, administrative medical assistants place calls for the medical practice to
patients, hospitals, clinics, and laboratories, as well as to insurance companies, suppliers, banks, and other
businesses.
Planning the Call
Plan the conversation before making a call by gathering important papers (such as the patient’s medical
record), obtaining necessary information, and outlining questions to ask. Know the specifics of the call
before you dial. Ask yourself who, what, where, when, and why, and make appropriate notations. Be
aware the following
• Whom to call and ask for once the phone is answered.
 • What information to give or obtain.
• Questions to ask.
• When to call,
• Possible situations that might arise during the call (what-if situations).
Using Resources
Numerous resources are available to the administrative medical assistant as aids in placing calls and in
managing the flow of the calls in a medical office.
Telephone Directories. An alphabetic directory, or white pages, lists telephone customers by name in
alphabetic order. The white pages usually contain other information such as directory-assistance numbers,
billing information, long-distance calling procedures, and area code maps. In large cities, information
concerning government agencies, including phone numbers, is often listed in the blue pages section of the
alphabetic directory.
A classified directory, or yellow pages, list telephone subscribers under headings for types of
businesses such as “Office Supplies or Laboratories-Medical.” Classified directories also contain
advertising for subscribing businesses and sometimes contain local maps and ZIP Code listings.
There are also many directory services available on the internet for example, AOL NetFind,
Switchboard.com, YellowPages.com, B2B (Business to Business) Yellow Pages, 55-1212, and many
more, these directories use search engines to locate phone numbers, addresses, and e-mail addresses
locally, in the United States, and in some cases, foreign countries.
A personal directory is used for phone numbers that are frequently called by the office staff. The
personal directory should be kept near the phone for easy access and would probably include a list of the
following phone numbers:

 Hospitals
 Insurance companies
 Laboratories
 Medical supply companies
 Pharmacies
 Hospital Emergency Room
 Specialist for referrals made to patients
Most phone systems are equipped with an automatic speed-dial feature that allows the user to store 20 or
30 numbers electronically.
Placing the Call
When you have the proper information and are prepared to a call, use the following procedures:

 Identify yourself and the physician office. If you are calling for the physician, identify the
physician.
 State the reason for the call
 Provide the necessary information
 Ask tactfully for information
  Listen carefully and make notes as needed
 Verify information
 If the person you are trying to reach is unavailable, leave a message for that person to call you
back. Remember to follow the confidentiality guidelines of the office.
Using Electronic Mail (E-Mail)
Message and files can be transmitted in digital from computer through an electronic mail system,
commonly known as e-mail. Electronic mail saves time conveys messages rapidly and promotes
flexibility. Users may access the system outside the office to send or receive e-mail messages and files
from home or other locations. Electronic voice mail operates in the same manner, strong voice messages.
It is critical to note that e-mail must be subject to the same strict privacy rules as other forms of
communication. The office adopts guidelines to protect the confidentiality of patient’s electronically
transmitted medical data.
Following Through on Calls
Proper handling of telephone calls does not end after the phone is bring up. The administrative medical
assistant must follow through on all requests made and instructions provided in the conversation. The
physician may wish to have all telephone messages entered into the patient’s medical record. In such
cases, the message slip can be taped or filed inside the chart after it has been acted on. Some offices may
have a page in the patient’s record specifically for messages.
Scheduling Appointments
Scheduling appointments is one of the principal duties of the administrative medical assistant. To be able
to do so efficiently and intelligently is an important skill. Appointment must be entered into an
appointment book or computer scheduling software. The assistant is responsible for collecting the
necessary data for an appointment, such as the patient’s name, phone number, and reason for making the
appointment.
Change in scheduled appointments, such as cancellations, must be indicated and the time slot used for
another patient whenever possible. The physicians outside appointments should be listed and, if
necessary, the physician reminded of them in advance. Clear and accurate communication between the
administrative medical assistant and the physician yields beneficial results for both the practice and the
patients.
Following the Physician’s Policy
The physician’s policy for seeing and treating patients is the initial guideline in scheduling. Policy may be
affected by the physician’s office hours, specially, how quickly the physician works, the treatment or
procedure to be performed, the available office personnel and equipment, and the type of facility. Office
Hours Before appointments can be made, the administrative medical assistant must know the basic
schedule of the physician’s office. The physician probably will have to make the rounds of patients at one
or more hospitals on certain days and at the certain hours. Office hours, therefore, may have vary on
different days. The administrative medical assistant should be aware of each physician’s hours as well as
how and where each physician can be reached at other times. While office hours may differ depending on
the requirements of the practice, a thorough understanding of specific policies within a practice
contributes to greater efficiency.
Types of Scheduling
An efficient scheduling system reduces the waiting period for patients, makes the best use of the
physician’s time, and takes advantage of available personnel and facilities. A number of systems are
commonly used.
Scheduled Appointments. Many physicians’ office and clinic use a scheduling system in which each
patient is given a set appointment time, that is, an approximate time the patient will be seen by the
physician. This system decreases the waiting time for the patient and gives the office staff more control
over the flow of the patients in the office. Also, because the reason for each patient’s visit is known in
advance, the staff can make the best use of the office facilities, equipment, and medical staff time.
Fixed Office Hours. Many clinics have fixed office hours during which the physician is in the office and
available to see patients-from 10 a.m. to noon. This system allows patients the freedom to come to the
clinic when they wish, but it has several drawbacks:
• The reason for the patient’s visit is not known until the patient arrives at the office.
• It is difficult to control the flow of the patients. Thus, many patients may arrive at the same time,
causing crowding and long waits. At the other times, there may be no patients, causing the physician’s
and the staff’s time to be used inefficiently.
• Equipment and office facilities may be used indifferently.
Wave Scheduling. One way to avoid these problems is to combine fixed office hours with scheduled
appointments. This system is called wave scheduling. The administrative medical assistant arranges for a
certain number of patients (such as six) to come between 9 a.m. and 10 a.m., then arranges for the next six
patients who call to arrive between 10 a.m. and 11 a.m., and so on throughout the day. Wave scheduling
gives patients the flexibility of open office hours while allowing the assistant more control over the flow
patients. This method works well in practices such as dermatology and endocrinology, in which the
physician often does not need laboratory and x-ray results in order to diagnose and treat the patient.
Double-Booking. When the schedule is full and there are more patients who need to be seen, some
offices used the method of double-booking appointments. The extra appointments are entered in a second
column beside the regularly scheduled appointments.
Computer Scheduling. A variety of computer scheduling software programs are used in medical offices.
Most scheduling software allows the user to search for the next available slot for the amount of time
needed.
In addition to a printout of the daily schedule, most scheduling software can generate reports of
cancellations and no shows. A no show is a patient who, without notifying physician’s office, fails to
show up for an appointment. Most scheduling programs can also be used to generate patient registration
information as well as chart labels for patients’ records.
Screening Patients’ Illnesses
When scheduling an appointment, the administrative medical assistant must use good judgement to
determine how soon a patient needs to be seen. This process is called screening, or triage (tree-ahj’).
Some patients must come to the office stat (the term used in health care to mean “immediately”), some
may be scheduled for later the same day or the following day, and others may be scheduled at a later time
that is convenient for both the physician and the patient.
The difference between stat and today appointments depend on the severity of the condition, which is
determined by the questions and answers received when talking with the seller. It is also always better to
make an appointment sooner than to leave a critical condition until later. Patients with life-threatening
conditions should be instructed to hang up and dial 911 or to go directly to an emergency room,
accordingly to office procedure.
Considering Patients’ Preference
The trend is to offer more convenient appointments to patients. Be aware that an appointment for
tomorrow can change into an emergency situation with the addition of another symptom. Some patients
prefer to be seen at a certain time or on a certain day of the week. Try to schedule appointments according
to patients’ preferences if the schedule allows, taking into consideration the urgency of the appointment
situation. Some physicians have office hours on certain evenings, such as every other Thursday evening,
or on Saturday mornings, to better accommodate their patients’ work schedules.
Necessary Data
When patients’ appointment are scheduled, all necessary data should be collected and recorded. In
general, this includes some or all of the following information:
• Patient’s first and last names
• Telephone number
• Address
• Date of birth (DOB)
• Reason for the appointment
• Patient status: new (NP). Established (EP), or referred by another physician
• Referring physician
• Insurance provider
• Notations regarding any laboratory test or x-rays required before the examination.

Always verify the patient’s name and its spelling and repeat telephone numbers. Confirm the appointment
time by repeating it to the patient. When patient arrives in the office, the information taken when the
appointment was scheduled should be verified.
Keeping To the Schedule
Any number of situations arise in the course of a day that require the administrative medical assistant to
cancel and reschedule appointments or to work an appointment into the existing schedule. In addition, the
assistant must adjust the schedule for any emergencies that arise as well as setup next appointment for
patients currently in the office who need a follow-up encounter with the physician.
Irregular Appointments
Occasionally a patient walks in without an appointment. If the physician is busy and it is judged that the
walk-in patient should be seen at that time, you may explain that the physician will see the patient for a
few minutes when the patient can be worked into the schedule.
A patient with a true emergency should be seen on arrival. The administrative medical assistant should
notify the nurse or physician of the emergency and escort the patient to an available examination room.
The assistant must tactfully explain the presence of walk-in and emergency patients to other waiting
patients who have made appointments that will now be delayed. If a physician outside the office calls to
request that a patient be seen that day by one of the physicians in your office, that patient must also be
worked into or added to the days scheduled.
On days when the schedule is full, the office nurse may be used to help determine whether a patient is a
truly an emergency case and to ask the physician for further instructions. In some cases, the physician
may request that emergency patients who telephone be referred to the emergency room.
In addition to appointments for patients, physicians have hospital commitments, seminars, lectures,
meetings, and personal appointments that may change at the last minute. All these changes must be
logged into the appointment calendar to avoid schedule conflicts later on.
Late Patients. The entire schedule may be thrown out of balance because a patient is late. Patients who
are late for appointments may have to be asked to wait until the physician has seen the next patient or
until a treatment room is available. It is not the administrative medical assistant’s place to criticize a
patient who is habitually late since it is an inconvenience to other patients.
Extended Appointments. Schedules also fall behind when either the physician or the patient loses track
of the time during an examination, causing the appointment to go past the allotted period. The physician
may have to be reminded if the visits run over the scheduled time. The administrative medical assistant
can use the intercom or knock on the examination room door and hand the physician a written reminder
when the physician comes to the door.
Out-of-Office Emergencies. The schedule may also be disrupted when the physician is called out of the
office for an emergency. The administrative medical assistant should explain the situation to waiting
patients and ask patients whether they wish to wait their physician to reschedule their appointments.
Registering Arrivals
Registering new patients on arrival at physician’s office or clinic is the duty of the administrative medical
assistant. Patients are asked to register, or sign in, on arrival. The assistant should then verify the patient’s
name, address, and other information with the patient’s record. If a computerized scheduling program is
being used, it is all the more important to verify the spelling of each patient’s name, since an exact
spelling will help to locate the patient’s appointment time and information quickly.
When the patient has signed in, the administrative medical assistant leaves the medical file for the nurse
or physician’s assistant, indicating that the patient is ready to be seen. The registration record can be
periodically checked against the appointment schedule to make sure that a patient who has arrived has not
forgotten to sign in.
Canceling and Rescheduling Appointments
Almost every patient will cancel an appointment at one time or another; some patients make a habit of
doing so. When a patient calls to cancel an appointment a new appointment time should be suggested. A
notation regarding the cancellation may also be entered into the patient’s medical record (especially if the
cancellation is made on the same day as, or the day before, the scheduled appointment).
If a manual schedule is kept, cancellations are noted by drawing a lone through the appointment and
entering a new one. As changes in the appointment book are made throughout the day, the assistant must
remember also to make the changes on the workstation schedule used by the physician and nurse.
No Shows
The administrative medical assistant should also make a notation in the patient’s medical record if the
patient fails to keep an appointment and does not call to cancel. The physician will decide what action to
take if a patient repeatedly makes appointments and does not keep them. Speciality practices sometimes
charge patients for no-show appointments or cancelled appointments when notification is not made
24hours in advance.
Next Appointment
Before a patient leaves the examination room, the physician will tell the patient when to return. When the
patient stops at the checkout area, the administrative medical assistant should inquire whether another
appointment is needed. In many offices, the need for another appointment-often referred to as a “recall-is
noted on the encounter form or in the patient’s medical record that is given to the assistant after the
appointment by the physician. Many offices use a system of follow-up telephone calls to remind a patient
of an appointment for the next day. If the follow-up appointment is several months in the future, the
patient may be asked to complete a postcard with the patient’s address before leaving the office so the
card can be sent as reminder to the patient.

Open Slots for Catching Up

No matter how carefully appointments are scheduled, crowding is sometimes unavoidable, and
appointments fall behind schedule. Leaving a 15 or 20munite interval free in the late morning and again
in the middle of the afternoon each day will help you to straighten out a delayed schedule.
Out-Of-Office Appointment
Appointments that may be scheduled outside the office include hospital admissions, surgery, and
diagnostic or other special procedures. Follow basic scheduling procedures for such appointments,
obtaining the necessary patient data required for each type of appointment.
Hospital Admission. The following information is needed for hospital admissions:
• Complete name of patient.
• Patient’s information
• Diagnosis or problem
• Preferred date of admission
• Accommodations preferred
. • Previous admissions
Surgical and Diagnostic procedures
• Surgery or other procedure to be preferred
• Length of time needed on surgery
• Approximate date and time desired
• Specific surgical assistants required
• Type of anesthesia to be used
• Special requirements, such as diagnostic testing
Other considerations for scheduling include:
• Scheduling the appropriate time required by the physician in each situation
• Giving patients clear and simple instructions for hospital admissions
• Informing patients about any preparations that are required before undergoing a surgical or
diagnostic procedures
• Confirming that any special assistants and/or anesthesiologist that have been requested are
available.
Managing Finances in Medical Office
Administrative medical assistants help with the accounting – the methodical recording,
classifying, and summarizing of business transactions in the medical office. The physician must have all
the records of all transactions and must be able to prepare tax records. Either an accountant employed by
the practice, or the Internal Revenue Service (IRS) may wish to perform an audit, or reviews of all
financial data in order to ensure the accuracy and completeness of dat. The assistant makes all the records
available to the IRS and keeps all source documents for tax purposes. These tasks require a working
knowledge of tax regulations and of the accounting process. The part of the process that is the accurate
recording of transaction is called bookkeeping.
Accounting for the practice may be done in one of two ways: on a cash basis or an accrual basis. If the
practice operates on a cash basis, charges for services are not recorded as income to the practice until
payment is received and expenses are not recorded until they are paid. With the accrual method, income is
recorded as soon as it is earned, whether or not the payment is received, and expenses are recorded when
they are incurred. Whichever way the practice decides to keep it accounts, there are certain essential
records that must be carefully kept and maintained. The assistant’s task is to enter data accurately the first
time on a record and to perform the tasks of posting to records or transferring amounts from one record to
another.
Essential Financial Records
The financial records that are used daily in the practice include the following:
• Daily Journal is a record of services rendered, daily fees charged, payments received, and
adjustments. It is also called a “general journal, “day sheet,” or “daily earnings record.”
• Charge/receipt slips provide a record of the physician’s services and the charges for these. Each
slip has a tear-off receipt for the patient.
• Ledgers contain a patient’s name, services rendered, charge, payment, and balance. Accounts
payable ledgers record expense amounts owed to a supplier or creditor. Accounts receivable
ledgers record the balance of payments due from patients or others on current accounts.
• Summaries The monthly summary shows the daily charges and payments for an entire month.
The annual summary provides the monthly charges and payments for an entire year. In some
practices, quarterly (a three-month period) summaries are prepared.
The assistant is responsible for accurately entering the data and keeping these essential records current.
These records are the basis for ongoing decisions about collections and disbursements, and they provide a
picture of the financial health of the practice. In all businesses, the managers speak of the importance of
the balance sheet, the financial statement for a particular date that indicates the total assets (possessions of
value, such as equipment), liabilities (debts), and capital (available cash). Summaries are an important
part of the balance sheet.
Banking
The administrative medical assistant is responsible for handling the banking functions accurately and
promptly because it contributes to the financial health of the practice. This includes preparing deposits
and reconciling bank statements. Banking tasks require absolute accuracy, correctness that one hundred
percent, because the assistant acts as the physician’s agent in these matters. The Banking Policy of the
Practice The physician must indicate the persons in the practice authorized to sign all checks. One person
may be authorized to write checks, and another may be authorized to sign. This is a good system to avoid
mistakes and misappropriations.
Checks and Checking
The practice may have at least two types of checking accounts – one regular business checking account
and an account that pays interest. There may also be savings account in the name of the practice. Money
for taxes or expenses that are not immediate will be kept in a checking or savings account where it will
earn interest, or money paid by the bank to depositors in return for the bank’s use of the depositor’s
money. You will use the regular business account most frequently: to deposit patient payments and to
draw checks for the payment of office expenses. Although this account does not pay interest, it allows for
availability and flexibility. No interest is lost by the frequent transactions.
Negotiable Checks
A check in order to a bank to pay a specific amount of money. In order for the check to ne negotiable, that
is, to allow the legal transfer of money, it must meet several requirements. It is important for you to know
what these are; you should examine all checks given to you before accepting them. To be negotiable a
check must:
• Contain the specific amount to be paid.
• Be made out (made payable) to the payee. The payee may be the title of the practice rather than
the physician’s name, depending on the title of the account.
• Carry the name of the bank that is making the payment.
• Specify the date on which payment is to be made.
• Be signed by the payer, the person who writes the check and is promising to pay the money. Be
sure that you understand and follow office policies about accepting checks. For example, a patient
visiting the office for the first time may be required to present identification before the check is
accepted.
The following kinds of checks are usually not acceptable:
• Postdated checks: A check dated in the future (postdated) cannot be cashed until that future
date.
• Predated checks: A check dated in the past (predated) is acceptable only if the date is within a
six-month period before the date which you receive it.
• Third-party checks: In this case, third party refers not to an insurer but to anyone other than the
patient. A third- party check is a check written to the patient by a person unknown to the practice.
• Check with annotation of “Paid in Full”: When the amount of the check does not correspond to
the total, or full, amount due for the services rendered, the office should not accept a check
marked “Paid in Full.”
Deposits
The checks and cash placed into the account belonging to the practice are called deposits. Once the
checks have been accepted and endorsed, a deposit slip is prepared. For a sizable practice, depositing
checks daily is important because it improves the cash flow and ensures that check is sent by the practice
will not bounce. If the practice is specialized or very small, deposits may be made less often during the
week.
Returned Checks
The bank may return a check that has not been completed properly: the check may be missing a date or
signature. The check will also be returned if there is not enough money in the account to cover the
amount shown on the check. In this case, the check is stamped, or identified “NSF” or “Nonsufficient
Funds.” When this happens, you will need to contact the person who gave you the check.
Bank Reconciliation
Each month the bank submits a statement of the checking account, such as the one shown in Figure 10.7.
The monthly statement shows the beginning balance, total credits (deposits added to the account during
the month), total debits (checks paid out of the account during the month), any service charges that apply,
and the resulting new balance.
The new balance on the statement must be compared with the check book balance to determine whether
there is a difference between the amounts. This process is known as reconciling the bank statement, or
bank reconciliation. Many banks provide a reconciliation form, such as the one shown in Figure 10.8, on
one of the pages of the monthly statement.
The steps you should take in the reconciliation process are:
1. Compare the cancelled checks returned by the bank with the items listed on the bank statement.
When the banks do not provide the actual cancelled checks, miniaturized Photostats of the checks
are usually provided. These, in addition to the listing of the checks on the statement, may be used
for reference.
2. Compare the checks listed on the bank statement with the check-book stubs to verify that the
check numbers and amounts agree. Deductions, such as service charges, are explained on the
bank statement. These must now be recorded in the checkbook. Checks that were written during
the last month but have not yet been paid by the bank are not included with the statement. These
are called “outstanding checks” and should be listed on the reconciliation form as shown in
Figure 10.8.
3. Compare the deposits recorded in the checkbook with the credits listed on the bank statement.
A deposit listed in the checkbook but not recorded by the bank at the time the statement was
issued is called a “deposit in transit.”
4. If the checking account earns interest, record the interest as a credit, similar to a deposit, in the
checkbook.
5. Complete the reconciliation form following the directions.
If the final amount on the reconciliation form does not agree with the amount in the checkbook, compare
the monthly statement with the checkbook again.
• Recheck the deposits entered on the bank statement with those you have entered in the
checkbook.
• Confirm that all service charges shown on the statement are entered in the checkbook and have
been properly deducted.
 • Make sure no check has been drawn that has not been recorded in the checkbook. Compare all
checks with the stubs to make sure the amounts agree.
• Review the list outstanding checks to see whether an old check is still outstanding.
• Recheck all addition and subtraction.
When the checkbook is reconciled, make a notation to that effect in the check book on the last-used stub
or register line.
Banking Electronically
Banking by computer can contribute to both efficiency and accuracy. The tasks that you have when
banking electronically is the same as those you perform when using paper procedures. You are still
responsible for recording and physically depositing checks. You will still need to reconcile statements;
However, the software will make all the calculations automatically. This is not only saving time but also
reduces the chances for error. You will no longer need to worry about a secure storage place for the
checkbook and deposit slips. The password that you determine in order to access the bank account is the
only item you must protect.
The software systems made available by banks require a modem attached to your computer. With a
modem in place, the bank makes the following activities possible:
• Checking balances in the accounts.
• Receiving electronic deposits.
• Finding out which checks have cleared.
• Transferring money from one account to another.
• Paying certain monthly bills.
In some cases, banks supply the software at minimal cost or have interfaces with commercial software.
The menus are easy to use. Main menus present choices such as “Pay Bills” and “Record Deposits.” The
directions for transactions are step by step. Reconciling monthly statements may also be done
electronically with a computerized version of the reconciliation form.
Petty Cash
A petty cash fund is a fund containing small amounts of cash to be used for small expenses. These
expenses are usually so small that checks would not be written to pay for them: cab fares, postage stamps,
payments to messengers, and delivery charges.
Each time you make payment form the petty cash fund, make an entry in the petty cash register or
complete a voucher if this is the system used in your office. The register or voucher provides a record of
these small expenses and ensures that only authorized payments are made from this fund.
To obtain money for the petty cash fund, the minor expenses for the month are estimated. A check for the
estimated amount is drawn, payable to the person in the office authorized to handle the petty cash fund.
The check is cashed, and the money is obtained in an assortment of small bills and change. The money is
kept in a secure place, such as a locked metal cash box in a drawer.
At the end of the month or when the amount of cash is low, the fund is replenished. First, from the record
in the petty cash register, determine the total amount of disbursements made. Count the remaining cash in
the fund. Be sure the two amounts add up to the original amount of the check that was cashed. This
procedure is called “providing the petty cash fund.” A new check is then drawn to bring the fund back to
its original amount.