How to manage clinical documentation securely in a new medical practice?

Jamie Frew
Jamie Frew
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Understanding clinical documentation and its importance in the healthcare space

Clinical documentation is an essential component of healthcare practices as it ensures that all relevant details pertaining to a patient’s health are recorded. Regardless of your healthcare discipline and the structure of your practice, clinical documentation is absolutely integral to the operations of your business. Roughly around 65% of patient medical health records contain misinformation and false tests, largely due to ambiguous abbreviations, sloppy handwriting, mixed patient data, and incorrect terminology, which is all very concerning! Failing to correct these mistakes could result in instances of misdiagnosis and ineffective treatments, which is obviously a big no-no for healthcare. Given the impact that unsatisfactory clinical documentation can have on patient outcomes, it is critical to take care to improve clinical documents, and ensure that patient information is correct, up-to-date, and accurately represents their health condition. Clinical documents are also great for healthcare professionals to consult and communicate on patient data, eliminating the need to refer to previous documents. As they work as stand-alone notes, there’s no need for you to tirelessly search through files to connect the dots for a patient’s health.  

Additionally, clinical documents are vital for businesses to be legally compliant with HIPAA standards, and to ensure that they are held accountable for any medical action. While we all make mistakes, it is important to recognize and correct them before they become legal issues that could result in serious repercussions. Your practice could be considered fraudulent or guilty of malpractice without the proper safeguards in place. HIPAA standards ensure that patient data is kept private within encrypted servers, and that only authorized users have access to specific information. It’s a win for both you and your patients to secure private information that complies with healthcare guidelines and laws, and allows you to do what you do best; provide the highest level of care!

6 ways to effectively manage clinical documentation securely for a new practice

If the idea of clinical documentation overwhelms you, don’t worry! We understand that it can be difficult to know where to start and how to best manage client documents, which is why we have compiled the top 6 ways to effectively organize and maintain medical document management. Incorporating this checklist into your clinic will bring about success for you and your patients, with strategies and resources that your healthcare team will come to really appreciate. 

Cloud computing services - Cloud solutions are an excellent way to store clinical documents, allowing them to be managed in real-time, and protected with secure, encrypted standards. Using tier3+ security, with armed guards and optional bio scans for access, only authorized users will be able to access patient data. Cloud systems also allow information to be accessed from anywhere, meaning that healthcare professionals all across the country can review and oversee patient information if needed.

Multiple data centers - Data centers are based in multiple geographic regions and allow for clinical documents to be available 24/7. It can be very frustrating when you aren’t able to find the right information when needed, which can also cause significant delays in the diagnosis and treatment process. Fortunately, data centers prevent interruptions by replicating data to ensure continuity, and to provide high-level patient care. 

Active-active failover - As a high availability clustering configuration, two nodes run the patient medical system simultaneously to provide more load balancing and business continuity. If this sounds complicated, and just went completely over your head, essentially all you need to know is that using active-active failover improves response times in your medical health system. This means your patients can have access to information quickly, and that data is corroborated across multiple sources for a high level of consistency. 

Azure-hosted security center - As Microsoft’s cloud computing service, Azure is a great way to optimize medical record management, and provide a high-quality service that mitigates security risks. This vendor monitors systems with real-time dashboard watching to allow for any weaknesses to be quickly identified, and to continually improve and modify your patient information to ensure it is accurate, and securely stored. 

Redeployment - Jeopardized or compromised systems need to be reinstalled quickly, with new servers, networks, and cloud resources resorted in minutes. This is the easiest way to ensure that information remains confidential and secure and that your infrastructure can be saved. Failing to do so could result in severe repercussions for you and your patients!

Data recovery processes - Recovery time objective (RTO) and recovery point objective (RPO) are essential performance indicators to implement to prevent data loss and provide backup support. Ideally, this should be measured in minutes for faster processing and data recovery. 

Clinical documentation feedback

Staying safe, secure and ahead with Carepatron's clinical documentation software

Carepatron is an excellent medical document manager that allows you to effectively organize client notes, compose them according to standard guidelines, all whilst complying with HIPAA guidelines. When it comes to managing client information, using the best electronic health records software can allow you to conduct faster business processes and transactions, as well as provide a higher degree of care for your patients. As one of the leading options, Carepatron provides a variety of benefits, including:

HIPAA compliance - With bank-level encryption servers, as well as restricted access to authorized users, Carepatron provides all the security support you need to keep patient data safe. You can rest easy knowing your sensitive data is highly secure, and that your patient's needs are placed first.

Clinical documentation templates - We know it can be difficult to write effective clinical notes, and especially with the variety of conflicting content out there, that presents their own do’s and don’ts! Carepatron provides embedded templates and resources in its service to cater towards your healthcare discipline, and provide an integrated learning process.

Interoperable userfaces - Not only can authorized healthcare professionals from any location, but all healthcare personnel can use Carepatron’s features regardless of their technical skill with its user-friendly software. With high levels of accessibility, patient data can be viewed and assessed regularly to achieve higher clinical outcomes. 

It’s free! - To access Carepatron features, you don’t need to worry about any hidden or added costs! You can have unlimited video calling, vast storage for clinical documents and medical billing and coding processes, as well as customer support 24/7, all for free. 

Conclusion

Clinical documentation is an excellent way to prioritize your patient needs and preserve client data in a secure manner to minimize risks of security breaches. Clinical notes serve as excellent points of reference to evaluate patient health, and their concise structure allows for universal transparency and communication across healthcare practices. They are a must-have in providing immeasurable value for your clinic, and especially with software such as Carepatron, you can easily manage client data in minutes. No more scrambling around paper files, or having to wait for information to be transferred, as clinical documentation provides an effective way to elevate the quality of your healthcare practice. 

Clinical Documentation app

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