7 examples of information that shouldn't be included in a health record

EHR: Improving quality of patient care

When it comes to EHR for both small and large practices, there are clear benefits that make them a great option for the needs of your health practice. Unconvinced? Here are a few reasons why you should consider implementing EHR software:

1. Increased legibility - With everything being online, there’s no need to handwrite notes and keep them on file. Electronic transcription means that medical errors due to poor handwriting can be reduced by more than 60% with increased efficiency, and spelling and grammar correction processes. Healthcare professionals will appreciate being able to read your musings!
2. Increased medication management - EHRs allow for adverse drug events to be reduced by 52%, with alert systems in place to notify healthcare nurses and clinicians whether they have the wrong medication. For example, with barcode scanning technology, if the wrongly prescribed medication is scanned, the system can alert the practitioner that they have the incorrect product. 
3. Relevant lab results - EHR systems can identify the relevant and critical points within lab results. Using this, they can then notify healthcare professionals when tests need to be re-evaluated and conducted further, or whether examinations need to be repeated. This also allows for faster processing of reports with significant results. For example, if there is an abnormal result in showing blood pressure levels according to the patient’s normal standards, the practitioner will be automatically notified. 
4. Improves efficiency - With EHRs, clinical outcomes improve significantly, assisted by the efficiency of data being stored online, and the ability to be accessed from anywhere in the world. Medical billing and coding processes also become much more efficient with automated content. Essentially, all authorized healthcare professionals have instant access, making it easier to collaborate and communicate. 

HIPAA compliance and EHR

To be HIPAA compliant means having an EHR system that is in alignment with HIPAA regulations, in addition to having HIPAA compliant practices. They’re a joint package, and medical compliance is not as simple as just using an EHR-certified system to fulfill your legal obligations within your private practice.

You need to have a security protocol in place to ensure that patient information is kept private and secure. For instance, this may include password protection and limiting the access of users. Because everyone in your organization has different roles, and to minimize any risk of security breaches, you need to ensure that only those who need access to certain information have the authorization to do so. 

Additionally, you need to make sure your staff are all trained to handle the EHR systems and are educated on HIPAA-compliant processes. This way, you can avoid miscommunication, with all employees knowing what is expected of them. If there are any lapses in knowledge, make sure you have the educational resources to get your staff up to speed.

You also must implement risk assessment into your security measures to avoid hacks, data leaks, and any fines. Naturally, there’s some inherent risk when it comes to dealing with sensitive information online, but with the right resources, you can easily stay HIPAA compliant and protect patient information.

What information should not be included in a health record?

When composing EHRs, there are multiple things that you shouldn’t include within health records. For the most efficient notes that prioritize the needs of your patients and practice, you need to keep the following in mind when using EHR as a SaaS:

1. Subjective opinions - EHRs are an objective medical tool, and so any personal comments or subjective opinions aren’t welcome. For example, if you have an unpleasant interaction with a patient, there’s no need to write information such as “Mr. Wilson was particularly grumpy this morning.” This can cause issues later down the line when other healthcare professionals review the information, and this can also affect the quality of the patient’s treatment. When it comes to health, you should be making objective judgments that any clinician can easily understand and agree with. 
2. Assumptions - You should never assume or speculate when it comes to patient health, as this can result in limiting treatment options based on what you think the issue is. After all, medical reasoning is very much centered around science, and simply jumping to conclusions doesn’t benefit anyone. For instance, if a patient comes in with a rash, you may assume this is an allergy since there’s no present flare-up. However, within a few hours, the patient could need serious hospitalization and treatment due to an underlying health condition, which you misdiagnosed based on assumption. 
3. Blame - Don’t blame others for why a patient hasn’t been treated fast enough or why some vital signs have been missed, or for any other reason at all. EHRs are based on the current condition of the patient, and so all you need to be concerned with is the state of the patient in front of you. This also means you can’t blame and doubt yourself! Be confident in your abilities, and take pride in the application of all the years of training you’ve been through. 
4. Financial or health insurance information - This information is highly classified, and health records don’t need to be concerned with this information at this stage. Financial and insurance information is confirmed later down the track, elsewhere. 
5. Legal information - This includes any correspondence with lawyers or attorneys, and doesn’t need to be in a medical record. Because it’s legal information, this will be noted in the relevant documents. 

Final thoughts

Medical health records contained in EHRs are an increasingly common and reliable practice used for healthcare businesses to be both HIPAA compliant and efficient. Because of the convenience of online storage that increases efficiency and communication across healthcare practices, EHRs are great for small and growing professional clinics. 

Healthcare platforms, such as Carepatron, support practices by providing the software to be able to effectively manage patient data whilst achieving business goals. Careparon offers a variety of helpful features to sustain high-quality EHR systems, including a clinical documentation space, online appointment booking systems, medical billing and coding services, as well as a place to communicate with clients. What’s not to love?

Above all, we hope that this has consolidated your understanding of the composition of health records, including what should be avoided. Now knowing what constitutes a high-quality EHR, and what to avoid, we wish you success in the launch and growth of your business. 

Further reading:

• Privacy in Health Care
• How emerging healthcare technology is changing the workplace for nurses