Maintaining medical records 1

Student's Name

Course Name

Course Code

Institutional Affiliation

Tutor

Date
Maintaining medical records 2

MAINTAINING MEDICAL RECORDS

The Healthcare system has changed through technology, predominantly in terms of electronic

medical records. Medical records are the most crucial record kept in a medical office. The

medical record contains the analysis of a patient's health condition as it includes medical history,

test results, and treatment information related to the patient's disease. Medical records can be

stored in paper or paperless records. Electronic Medical Records are becoming popular over

paper records. Electronic Medical Records are digital collection and retrieval of a patient’s health

records.

Most hospitals have adopted the EMRs system, and this has helped provide accurate, complete,

and up-to-date information about patients, thereby enabling quick access to patient's records for

more efficient care. Also, EMRs has reduced medical errors and provided accurate record aiding

in more efficient diagnosing of patients.

EMRs enable accurate coding and billing. Medical centers require proper documentation of

patient's records. Coding describes the health problems of the patients, which steers the patient’s

bill. Any inaccuracies can lead to problems with health insurance companies and Medicare

leading to fines. EMRs technology enables proper documentation and contains the patient's

databases.

EMRs track patient healthcare costs and utilization. These include a number of tests, a patient's

visit, a number of tests, and all services. Data taken is used for budgeting, allocation of

resources, and calculating costs. This EMRs protects patient's confidentiality as it prevents

unauthorized access to patients' medical records.

Challenges of utilizing medical records

Maintaining medical records 3

EMRs are costly hence hindering its utilization as hospitals have to purchase the software and

employ experienced IT staff. Also, the lack of interoperability is a challenge as systems cannot

be able to communicate with each other in various institutions for patient’s records. EMRs play a

role in physician's burnout due to tiresome user interface as more amount of time is needed for

data entry. This lowers job satisfaction and reduced patient care. Also, there are slow systems,

either due to poor networks or software.

Medical Assistants and billing and coding professionals should learn both paper and paperless

methods as there is slow adoption to Electronic Medical Records. EMRs are prone to change and

are revolutionized every now and then, making it difficult to learn one system. EMRs, in general,

are advantageous over paper records, and these make many health institutions adopt an electronic

way of medical recording.

Medical Assistant role in the medical insurance process

Healthcare coverage is a sort of protection that takes care of the expense of your well-being,

related agent costs like medical cost or surgical costs.

While working as a Medical Assistant or Billing and Coding professional, knowing medical

insurance would benefit me in that I will be proficient in billing out claims both for the medical

facility I work for and for the patient. I would benefit from knowing various types of medical

insurances as I will be involved in billing. I would know different advantages given by insurance

agencies alluded to as "additional items." I would undoubtedly look for good medicinal care for

patients as well as advising for the importance of purchasing medical coverage to secure

themselves. Patients will free themselves from budgetary worry due to costs associated with

different insurance companies. Knowing the payers will prevent unnecessary billing problems
Maintaining medical records 4

assuring medical centers of payment. I would know what the insurance company covers for each

patient. I would organize for restorative treatment in other hospitals under the insurance cover

stated in case medication fails in the hospital I work for. This knowledge will benefit the patient

as I will advise on terms of different health insurance companies before purchasing an approach.

References

Miller, R. H., & Sim, I. (2004). Physicians’ use of electronic medical records: barriers and

solutions. Health affairs, 23(2), 116-126.

Barrows Jr, R. C., & Clayton, P. D. (1996). Privacy, confidentiality, and electronic medical

records. Journal of the American Medical Informatics Association, 3(2), 139-148.

Cutler, D. M., & Zeckhauser, R. J. (2000). The anatomy of health insurance. In Handbook of

health economics (Vol. 1, pp. 563-643). Elsevier.