One of the administrative functions of a medical assistant is maintaining medical records of the patient under the care of the medical institution or practitioner he or she is working with. Learning how to keep and maintain medical records is one of the requirements for licensing and or certification.

The MA sees to it that the medical record of a patient must be ready whenever the practitioner sees him or her. In this manner the doctor can review the record and see what medicine he or she is currently giving his or her patients, what tests had been done and the lab results needed in diagnosing the patient. After which the recommendations, prescriptions, diets, procedures that was done to the patient on that session will be recorded by the practitioner. The medical assistant will see to it that the record will be put back to the filling cabinet. In that way it is secured. Losing any page, unauthorized accessing and tampering must be avoided at all times.

The medical assistant must know by heart the ones who have rightful access to the medical records of the patients. The patient upon request can have a copy of his or her record. In case that the patient is unable to make personal decisions like a comatose patient, children of legal age, brother or sister of legal age, nearest relative or legal guardian may access the medical record. In an emergency and the patient is unconscious the healthcare people can access the record. Medical records of children can be access by their parents or legal guardian if they don’t have parents. Medical researchers can access the record if the research that they are doing is relevant to the illness of the patient but without disclosure of the identity of the patient. Authorities may also access the medical record of a patient for some reasons but could not be charge base on the medical record. » Read more: Medical Assistant Roles – On Maintaining Medical Records and Consent