Group 1 Medical Office 1

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MODULE 3 :
MEDICAL OFFICE
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1. What is Medical Office ?*

. Medical office buildings, or MOBs,
are office facilities designed
specifically for health care practices,
meaning they have elements or design
principles intended to improve patient
outcomes and enhance the patient
experience.
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1.1 MEDICAL OFFICE*
A professional office used by

medical doctors , dentists,
optometrists or drugless
practitioners for the purposes of
consultation,
diagnosis or treatment .
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2.WHAT IS MEDICAL SECRETARY?

Medical secretaries work in hospitals, doctor's
offices, private practices, medical clinics, and
more to support physicians and other medical
professionals. Their role is comparable to that of a
clinic assistant. These administrative professionals
handle the bulk of bureaucratic duties in a medical
setting.
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2.1 MEDICAL SECRETARY

● The Medical Secretary will perform secretarial
duties using specific knowledge of medical
terminilogy and knowlegde of medical
terminology and hospital ,clinic or laboratory
procedures.
● Duties will include scheduling

appoinments,billing patients,and compiling and
recording medical charts,reports and
correspondence.
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3.Duties Responsibilitiies :
● Greet visitors ascertains purpose of visit and directs them to appropriate staff.
● Interviews patients to complete documents , case histories, and forms such as intake and insurance
forms medical charts, reports, and correspondence using
a computer and various software programs. Transmits correspondence and medical records by mail ,
email , or fax.
● Schedules and confirms patient diagnostic appointment, surgeries , and medical consultations.
● Answers telephones and direct calls to appropriate staff.
● Receives and routes messages and documents such as laboratory results to appropriate staff.
● Operates office equipment such as voicemail messaging systems, and uses word processing ,
processing , spreadsheet, and other software to prepare reports invoices financial statements , letters,
case histories and medical records.
● Maintains medical records , technical library, and correspondence files.
● Performs various clerical and administrative functions such as ordering and maintain an inventory of
supplies.
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4.Keen listening and Spelling

● Medical Secretaries must be able to focus and listen carefully
to the words that a doctor says. Whether the secretary uses
dictation equipment and types the doctors recorded words or
medical staff is right there explaining something. It is essential
that the correct words . Terms and letters are heard , interpreted
,spelled and typed for permanent record.
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55
ORGANIZATION
● Organization is working together in a coordinated way to achieve goals.
Organization allowed individuals to specialize and increase efficiency.
● In general, secretaries are expected to be well organized in the medical

industry, this organization is especially vital because a person's life may
depend on the secretary's ability to grab a certain file quickly and find
particular information within that file without hesitation.
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5.1. FAST TYPING SPEED

● Medical secretaries are naturally transcriptionists, Most transcription schools certify
only typists who have reached a minimum typing speed of 45 words per minute with
100 percent accuracy
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5.1. FAST TYPING SPEED

● Learning to type fast and accurately will help you in many ways, these are some of the touch typing benefits and
advantages:
● Save time: This is the most obvious of the advantages; the fastest you type, the more time you will save, and on
average, when people learn to touch type, they can type 2.5 faster than when using only two fingers.
● Be more productive: When saving time and improving the accuracy, you can simply give yourself more time to
spend on other things, or do more in the same amount of time. You will also be able to edit as you go, because as
you stare at your screen, you will see errors as they appear.
● Improve your health: There are many health issues you can prevent by touch typing. You will become more aware
of correct posture when you learn to type properly, preventing your wrists from causing you pain, and as you don’t
have to keep looking down at your keyboard, it will reduce neck aching. It will also reduce both mental and
physical fatigue when typing for long periods of time.
● Improve your focus: As you will not have to look at the keyboard and think about where your fingers are going,
you will be able to focus more on what you are trying to say than the actual letters that you are typing. Every time
you look down and try to find a key, you are losing concentration.
● Find more opportunities: Typing is not an optional skill anymore, many jobs require computer skills and a certain
typing speed. Learning to type fast, and to do so accurately, can be one of the most invaluable skills of your career.
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5.2
5.2 GOOD COMPUTER SKILLS
● Computer skills at work refer to the knowledge and ability to use various digital
tools and technologies to complete job tasks efficiently and effectively. These skills
can include: The ability to use a computer, navigate the internet, and use common
software applications such as Microsoft Office.
● With the development of modern-day technology such as the Internet, office

programs and word-processing software, employers expect secretaries to have well
rounded knowledge and understanding of computers document programs and
virtual software
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6.MEDICAL OFFICE
POLICIES/PROCEDURES
Patients' consent forms, such as onset for procedure or treatment
form, patient education form, consent for medical or surgical
procedures and consent forms for invasive surgeries and
procedures should be kept, copied and filed accordingly.
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77 OBJECTIVES OF MAINTAINING
MEDICAL RECORDS
• Monitoring of the actual patient.
• Medical Research.
• Medical/Dental or paramedical education.
• For insurance cases, personal injury suits, workmen's
compensation case, criminal cases, and will cases.
• For malpractice suits.
• For medical audit and statistical studies.
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8.MEDICAL OFFICE
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99 MEDICAL HEALTH RECORDS

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10. ALTERING MEDICAL RECORDS

- While writing the medical notes, as far as possible do not overwrite.
- Do not alter the notes retrospectively.
- Entries in a medical record should be made on every line.
- Amend on electric record by striking through rather than deleting and
overwriting the original entry.
- Correction of the personal identification data of the patient like name, age,
father/husband name, and address should only be made on the basis of affidavit
attested by notary or 1st class magistrate.
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11.WHO HAS ACCESS TO MEDICAL

RECORDS ?
- Medical records are the property of the hospital or patient’s medical practitioner.
- All patients
- Patients’s legal representative
- Other health care providers
- Parents of a minor
- Medical records are usually summoned in a court of law in certain cases like-road traffic accident,
medical negligence, insurance claim etc.
- The impersonal documents have been used for research purposes as the identity of the patient is
not revealed.
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12. BP MEASUREMENTS
BP measurement stands for blood pressure measurement. It's a vital sign
that indicates the force of blood against the walls of your arteries as
your heart pumps it around your body. It's typically expressed as two
numbers: systolic pressure (the top number) and diastolic pressure (the
bottom number), measured in milimeters of mercury (mmHg). High
blood pressure can indicate health risks like heart disease and stroke,
while low blood pressure can lead to symptoms like dizziness and
fainting.
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13.LEGAL ETHICAL HEALTH CARE

CONFIDENTIAL AND PRIVACY
The information cannot be disclosed without that person's

explicit consent unless there is another valid legal basis. It
is irrelevant whether the individual is old or has mental
health issues or indeed lacks capacity: the duty still
applies.
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14. RELEASE OF RECORDS

- Request for medical records by patient or authorized attendant should be
acknowledged and documents should be issued within 72 hours.
- Maintain the register of certificates with the detail of medical records issued
with at least one identification mark of the patient and his signature.
- Effort should be made to computerize the records for quick retrieval.
- Certain document must be given to the patient as the matter of right.
- Doctors are not under any obligation to produce or surrender their medical
records to the police in the absence of valid court warrant.
- A subpoena to produce clinical records is a form of court order.
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15.CARE WHILE ISSUING CERTAIN

MEDICAL RECORDS
● PRESCRIPTION
- The prescription should be preferably on the OPD slip of the
institution or on the letter pad of the doctor.
● REPORTS
- All reports, ex. Lab investigation, x-ray reports, ultrasound reports,
computed tomography (CT-scan)/magnetic imaging resonance
(MRI) reports and histo-pathological.
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16.REFERRAL NOTES
REFERRAL NOTES
• Always keep the carbon copy of referral note especially in case
of critically ill patient.
DISCHARGE CARD
• Consultant in-charge should himself fill or supervise the
discharge card. Condition of the patient on the admission,
investigation done, the treatment given and detail advice on
discharge should be written on discharge card
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17.CERTIFICATES
A medical certificate is defined as a document of written evidence vouching for the
truth of a fact as determined by the doctor issuing such a document.
1. Medical certificate should be on institution/doctor letter pad.
2. Date, time, and place should be mentioned.
3. Issue it only for legitimate purpose and only when necessary.
4. It has to be true and clear without any ambiguity.
5. There should be an identification mark of the patient, preferably a thumb
impression.
6. Period of illness should be clearly mentioned.
7. Diagnosis disclosure of the diagnosis should be only after the patient’s express
consent, unless required by the law
8. Doctor should maintain the duplicate copy of every certificate.
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18.HOW LONG MAINTAIN THE

RECORDS
1. Ideally records of adult patient are maintained for 3 year.
2. 21 year for neonatal patient (3 + 18 year).
3. For children 18 year of age + 3 year.
4. For mentally retarded patient forever till hospital/institution
is working.
5. From income tax point of view for 7 years.
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19.HOW TO DESTROY THE

RECORDS
● To destroy the records, you need to:
● - Place public notices in an English newspaper and one vernacular paper,
stating the specific date up to which the destruction will occur.
● - Allow a one-month period for individuals to request their records with
written consent.
● - After the one-month period, proceed with destroying the records up to the
specified date, with some exceptions.
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20.HARD COPY ONLY

Despite the widespread use of computers for electronic
patient records in institutions/hospitals, certain documents
still require hard copies:
- Consent forms
- - Doctor referrals
- - Police case documents
- - Certificates of fitness
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21. PROBLEM OF RECORD

MANAGEMENT
There are many problems faced byinstitution/hospital for the proper maintenance
of the Records :
● Constant revision of the outdated form is needed
● Always trained personnel are needed for the maintenance
● Inactive records need storage at appropriate place
● There must be a need of determination of record retention
● Unwanted records must be destroyedRecord storage entall into 2 stages
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22. PROPER PRESERVATION OF THE

MEDICAL RECORDS
● Collect all the records and classify them according to the different
section Protect the records from insect attack. Spray insecticide
or place naphthalene balls over shelves to preserve the records.
Proper care should be observed while handling the records. Fire
extinguisher should be available in record room.
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B.RECEPTION PROCEDURES
● The medical receptionist is responsible for greeting patients, managing sign-in

sheets, locating medical files, distributing forms and guiding patients to the
waiting area and be available for questions. As the communication hub of the
medical office, the receptionist communicates through calls and emails,
handles correspondence, maintains electronic files securely, and updates
patients on doctor availability.
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C. FINANCES AND INSURANCE

PROCEDURES
● The medical receptionist also organizes payments,
billing Information, credit card payments, insurance
details and send financial notices like 60 days past due,
final notice, bad check, and overpayment notices.
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D.RULES AND REGULATIONS

PROCEDURES
● -To maintain a smooth running medical office
employees follow strict guidelines, rules and
regulations. Employees admire to uniform codes, daily
check-ins and out, a strict no drinking and no smoking
policy and fill out time cards.
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E. ADMISSION PROCEDURES
Direct admission/ER Admission
-Step 1: Secure Physician admitting orders sheet Doctors.Order (PAOS) or admission Notice slip
from Emergency Department.
- Step 2: Gather data and secure consent for admission.
- Step 3: Verify accomplished forms for completeness and accuracy of data. --- Step 4: Confirm
room preference and coordinate with nursing station.
- Step 5: Encode patient data general admission.
- Step 6: Provide information and explain hospital guidelines in admission. - Step 7: Issues patient
rights responsibilities handout admission kit and patient wristband.
- Step 8: Assist patient to room of choice
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F.PATIENT CARE POLICIES
● Patients care policies and procedure for hospitals

should be the most comprehensive set of
policies. These policies are guidelines for how
doctors and nurses care for their patients.
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G.MEDICINE POLICIES
● Studies shown that medication mistakes are the most common type of
medical error. While a patient is in the hospital, it’s up doctors and nurses to
make sure they get the medicine they need.
● Most health care especially nurses, know the “five rights” of medication use:
● the right patient
● the right drug,
● the right time
● the right dose
● the right route all of those rights are generally regarded as a standard for safe
medication.
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FOR
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Contents

1. What is Medical Office ?*

1.1 MEDICAL OFFICE*

A professional office used by

2.WHAT IS MEDICAL SECRETARY?

2.1 MEDICAL SECRETARY

● Duties will include scheduling

4.Keen listening and Spelling

● In general, secretaries are expected to be well organized in the medical

5.1. FAST TYPING SPEED

5.1. FAST TYPING SPEED

● With the development of modern-day technology such as the Internet, office

99 MEDICAL HEALTH RECORDS

10. ALTERING MEDICAL RECORDS

11.WHO HAS ACCESS TO MEDICAL

13.LEGAL ETHICAL HEALTH CARE

The information cannot be disclosed without that person's

14. RELEASE OF RECORDS

15.CARE WHILE ISSUING CERTAIN

18.HOW LONG MAINTAIN THE

19.HOW TO DESTROY THE

20.HARD COPY ONLY

21. PROBLEM OF RECORD

22. PROPER PRESERVATION OF THE

● The medical receptionist is responsible for greeting patients, managing sign-in

C. FINANCES AND INSURANCE

D.RULES AND REGULATIONS

F.PATIENT CARE POLICIES

● Patients care policies and procedure for hospitals

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