Domain 10.4Administrative Assisting

Medical Records Management

Last updated June 16, 2026

Overview

The medical record is a legal document ensuring continuity of care. MAs must master the organization, charting formats, and filing systems used to manage these records.

1. Charting Formats

  • POMR (Problem-Oriented Medical Record): Organized around the patient's specific health issues. Begins with a Problem List (the "table of contents").
  • SOMR (Source-Oriented Medical Record): Organized by the source of information (e.g., all labs together, all provider notes together). Filed in reverse chronological order.

2. SOAP Note Charting

  • S - Subjective: What the patient Says (Symptoms, history).
  • O - Objective: Observable data (Vitals, exam findings, Lab Results).
  • A - Assessment: Diagnosis.
  • P - Plan: Treatment, referrals, prescriptions.

3. Filing Systems

The 5 Steps of Filing

  1. Conditioning: Removing clips, stapling, mending.
  2. Releasing: Marking/stamping the document as ready to file.
  3. Indexing: Deciding where to file (determining units).
  4. Sorting: Arranging in order before going to the cabinet.
  5. Filing: Storing the document.

Indexing Rules

  • Unit 1: Last Name.
  • Unit 2: First Name.
  • Rule: "Nothing before something" (Smith comes before Smithe).

Filing Methods

  • Alphabetical: Direct system.
  • Numerical/Terminal Digit: Indirect system (requires a cross-reference). Good for confidentiality.
    • Terminal Digit: Read from Right to Left. The last group of numbers is the primary filing unit.
  • Color-Coding: The best system for preventing and finding misfiles.

4. Managing Information Flow

  • Incoming Reports: All reports (labs/consults) must be reviewed and initialed by the provider BEFORE being filed. This is a critical safety rule.
  • Outguide: A marker used to track a physical chart that has been removed from the cabinet.

5. Daily Chart Preparation

Before patients arrive, MAs must ensure the provider has everything needed for the visit.

  • Collating: The process of collecting and organizing all medical records, test results, and information for a patient who is scheduled for a visit.
  • Goal: To ensure the provider has a complete picture of the patient's status before walking into the exam room.

Memory Aid: To remember Collating, think of it as "Collecting" all the pieces for the appointment.