NHA Certified Clinical Medical Assistant (CCMA)Administrative TasksMedium
A medical assistant is reviewing a patient's medical record and notices that several entries are unsigned and undated. According to best practices and legal requirements, which of the following actions should the medical assistant take?
- ADelete the unsigned entries and ask the provider to re-enter the information.
- BBring the unsigned/undated entries to the attention of the provider or person who made the entry for correction.
- CSign and date the entries themselves, noting 'error correction.'
- DLeave the entries as they are, as altering them could be seen as tampering.
Show answer & explanationAnswer & explanation
Correct answer: B. Bring the unsigned/undated entries to the attention of the provider or person who made the entry for correction.
Medical record entries must be signed and dated by the person who made them. If entries are missing this information, the medical assistant should notify the original author to ensure proper completion and adherence to legal and ethical standards for documentation.
Why the other options are wrong
- A. Deleting entries is never appropriate, as it removes information from the legal record and could be seen as destruction of evidence.
- C. A medical assistant should never sign or date entries made by another provider, as this is falsification.
- D. Leaving incomplete entries is a violation of documentation standards and could lead to legal issues or poor patient care.
Medical Record Documentation Standards
Medical record entries must be accurate, complete, legible, signed, and dated by the person making the entry to ensure legal validity and continuity of care.
- All entries must be signed and dated by the author.
- Corrections must be made without obscuring the original entry.
- Documentation should be factual, objective, and timely.
Memory trick: Accurate records require the 'AUTHOR's' touch.