Medical Records Check-up (Spring 1995)

Spring 1995 pages 9-11 Medical Records Check-up Do you ....     Write legibly or use transcription?     Use clear, concise language?     Date and sign entries? (Particularly if in a group practice?)     Avoid improper alteration of the medical record?     Avoid using non-standard abbreviations?     Document what a patient tells you and what you tell a patient?     Obtain and file patient authorization for record release? (Review applicable state laws on release of medical records)     Include consulting physicians reports/notes?     Include disability reports and other information from others participating in patient's care?     Sign reports and dictation only after review? Medical Records Check-up. CPT® Assistant. 1995; Spring...

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Note:  The following article synopsis was NOT provided by the AMA. It was created by Find-A-Code/innoviHealth.

Article Overview

This article reviews basic medical records documentation and maintenance practices discussed in a Spring 1995 CPT Assistant piece. It is relevant to physicians, practice managers, coders, and other healthcare staff who handle documentation, record release, and chart integrity, and it addresses general recordkeeping habits and related administrative considerations.

Why This Topic Matters

Accurate, complete medical records support clinical communication, billing integrity, and appropriate handling of patient information. The article is useful for readers looking to assess whether routine documentation and record-management practices align with expected office standards.

Article Sections

  1. Spring 1995 pages 9-11

    An overview of common medical record documentation and file-management practices discussed in the Spring 1995 issue. The section frames a practical self-check for routine charting, correspondence, and record retention workflows.

What You Will Learn

  • What basic documentation habits are highlighted in the article
  • What record-handling and file-maintenance topics are emphasized
  • What general administrative areas are included in the Spring 1995 discussion of medical records
  • What types of documentation and release considerations the article raises

Who Should Read This

  • Physicians
  • Coders
  • Medical office staff
  • Practice managers
  • Health information management personnel

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