Chart what you did — accurately, promptly, and in your lane
⚠ DRAFT — pending sign-off; MA works under provider direction and does not diagnose or prescribe
0 Coins
💧 0 Drops
📊 0% complete
K
Coach Katie
The chart is how the whole care team knows what happened. As a Medical Assistant you document what you did — accurately, objectively, and on time. The rule to remember: if it isn't documented, it wasn't done.
What the record is
The electronic health record (EHR)
The EHR is the shared, legal record of a patient's care. Every entry you make should be accurate (what really happened), objective (what you observed and measured, not your opinion), and timely (charted right away, while it's fresh — not hours later from memory).
If it isn't documented, it wasn't done. Care you performed but never charted can't be seen, billed, trusted, or defended. Chart it promptly and factually.
Stay in your lane
What an MA charts — and doesn't
✅ Chief complaint
The reason for the visit, in the patient's words.
✅ Vital signs
BP, pulse, temp, respirations, weight, etc.
✅ Med & allergy list
What you reconciled with the patient.
✅ Tasks performed
EKG, injection given, specimen collected.
🚫 Diagnoses
The provider owns the diagnosis — not the MA.
🚫 Assessments beyond your role
Interpreting results or judging severity.
Document facts, not conclusions. Chart "patient reports chest tightness" — not "patient is having a heart attack." Diagnosing and assessing severity belong to the provider.
When you make a mistake
Correct — never delete
The EHR is a legal document. If you chart something wrong, you never delete or erase it. Instead you add a dated, time-stamped correction or addendum that shows what was changed and why. The original stays visible; the correction is added on top.
Deleting an entry looks like hiding something. An addendum with the date and time keeps the record honest and protects you, the patient, and the practice.
Privacy in the chart
Confidentiality & HIPAA in the EHR
Minimum necessary: open only the records you actually need to do your job — nothing more.
Never share logins: your credentials are yours. Everything done under them is tied to you.
Log off when you step away so no one uses your open session.
Curiosity is not a reason to look. Accessing a chart you aren't caring for — even a friend's or a celebrity's — is a HIPAA violation.
Getting the list right
Med & allergy reconciliation
At each visit you confirm the current medication and allergy list with the patient — what they're actually taking, the dose, and any allergies or reactions. If what the patient says doesn't match what's in the chart, you flag the discrepancy to the provider.
You reconcile and flag — the provider decides. Don't change a prescription or clear an allergy on your own. Surface the mismatch so the provider can act.
K
Coach Katie
Two real moments at the keyboard. Pick the response that keeps the record accurate, honest, and HIPAA-compliant.
K
Coach Katie
Five questions. 75% to pass, then make your pledge.
K
Coach Katie
Learning sticks when you commit to a next step. Pick at least two pledges you'll actually do.
0 Coins