Good medical recording keeping is a vital part of providing safe and efficient patient care. Medical records are used to determine a patient’s history, identify potential risk factors, analyze past treatments and diagnose new illnesses. Apart from being essential for an effective medical practice, good medical record keeping also plays an important role when it comes to complying with regulations like HIPAA and others.
Proper medical record keeping helps ensure that doctors make informed decisions about the course of treatment for patients. By employing the services of a medical document scanning company, your files can be scanned quickly, sent to the required destinations in various formats, and made accessible anytime.
What Is Good Medical Record Keeping?
Medical record keeping is a systematic approach to storing and retrieving health information using electronic or physical systems. Efficient medical record keeping can help healthcare professionals deliver better care by making it easier and faster to find detailed information about a patient. Medical data includes documents such as patient history, clinical findings, diagnostic test results, pre- and post-operative care, patient’s progress notes and medications, hospital discharge summaries, and ambulatory notes.
It has set methods that help staff to quickly locate the exact information needed. This will enable providers to spend more time caring for their patients and less time trying to find out the information which is essential for accurate diagnosis, error prevention and speedy recovery.
Here are some of the important medical documents that need to be well-maintained:
- Handwritten notes by healthcare practitioners
- Medical notes by previous practitioners including a typed patient discharge summary
- Referral letters from other physicians
- Lab reports and lab evidence like cytology slides and printouts from automated analyzers, X-ray films and reports, ECG traces, etc.
- Audio or visual records like photographs or video tape recordings
- Clinical research forms and clinical trial data
- Other healthcare-related forms like insurance forms, disability assessment, and documentation of injury on duty
- Death and autopsy records
Tips for Good Record Keeping
- Be accurate, factual and consistent.
- Update the medical records as soon as possible in case of any recordable event.
- Provide current information on the care and condition of the patient.
- Medical records should be documented clearly so that the text cannot be erased.
- The records must be consecutive and accurately dated, timed, and all entries signed (including any alterations).
- Any original entries should be legible. Draw a clear line through any changes or deletions; and sign and date the entries.
- Never include any abbreviations, slang or jargon in the medical records as all workplaces or organizations may not use the same terminology.
- Records must be stored securely and should only be destroyed following your local policy.
- Avoid meaningless phrases, speculation and offensive subjective statements/insulting or derogatory language.
- Identify the patient by recording the patient’s name, date of birth and hospital number on each page of the record, or follow your local policies on how to identify patient records.
- Make sure the medical records are legible even if they are photocopied or scanned.
- Make sure that the dates and signatures are all good and ensure that the records are accurate and error-free.
- Any correction must be clearly shown and complete it and enter the date the amendment was made, and your name.
- Writing good medical notes should become a routine.
- Any discussions made, information given, relevant history, clinical findings, patient progress, investigation etc. should be documented.
- Medical records can be in the form of handwritten notes, computerized notes, lab reports, imaging records, photographs, video and other recordings, and data from other monitoring equipment. So, ensure that all these are well-maintained.
- Never write any offensive or gratuitous comments. The records should have only relevant information.
- Remember that patients have access to their medical records under Promotion of Access to Information Act.
- Good medical record keeping and best practices to keep the medical records help to minimize risks and allows better communication between healthcare professionals.
- Well-organized and complete medical records are vital for an efficient medical practice and continuity of care. They are important for a healthcare professional’s defense in case of any complaint and also reflect the quality of care.
- Proper medical record keeping is an essential component of professional standards.
Importance of Good Medical Record Keeping
Medical record keeping is an integral part of any healthcare business. Medical records encompass the records about patients that are kept manually as well as digitally for future reference, for tracking events, as well as for treatments as a part of healthcare delivery. Keeping accurate records not only improves the quality of services being delivered and facilitates continuity of care, but also makes them more accountable. Failing to keep proper records can land you in serious trouble with the law and lead to costly fines and loss of reputation. Poor record keeping can be a major concern for patients too. Poor record keeping has a detrimental effect on the quality of patient care, therefore it is important to keep medical records properly and updated.
Medical records provide clinical information that enable future physicians and other health care professionals to make appropriate decisions when treating patients. In addition, they help in tracking the medical history of patients and make it easier to obtain relevant information during emergencies. They also serve practice revenue-related purposes like obtaining reimbursement from insurance companies. Good record keeping is a product of good teamwork and a vital tool for developing high-quality healthcare and reinforcing professionalism within nursing.
The medical field is constantly evolving and changing to meet the needs of patients, leaving medical professionals with little time to manually track all the necessary records in their medical facility, when they are paper-based. That’s why it is important to choose the right medical document scanning services for your business that can maintain confidentiality during every step of the digitization process. Moreover, document scanning and digitization are vital since patient data has to be stored electronically, with EHR and EMR systems becoming mainstream.