Medical records management doesn’t have to be complicated, and with the right implementation of tips, you can ensure you are effectively storing and maintaining your records.
- Be objective - Because other healthcare professionals may review and assess your notes, you need to ensure that what you write is consistent with medical health processes and diagnoses. For example, you should not deem a patient as ‘an alcoholic’ and that they ‘abuse drugs’ without evidence to support these statements. This can be potentially harmful, and instead, you should remain objective by stating the patient demonstrates ‘drug-seeking behavior.’
- Be timely - Medical record entries should be dated, and composed neither too early nor too late following a session with a patient. Leaving it too late poses the risk of missing out on critical details due to natural memory loss, whilst completing it too early can interfere with the patient’s session. Any delays in writing notes need to be recorded before the relevant staff goes off duty.
- Don’t use abbreviations - Abbreviations can be ambiguous, so it is best to avoid them altogether. For example, PID could mean prolapsed intervertebral disc or pelvic inflammatory disease. Universal short forms are more acceptable if required.
- No unnecessary comments - In line with being objective, you should never make offensive, humorous or personal comments. Medical records are classified documents of information that need to be evaluated within a professional context.
- Document non-compliance - If a patient fails to follow directions or advice, or doesn’t take their medication, it is best to note this in the record. This can help in the case that such issues evolve into a much larger legal scale.
- Document all interactions - Phone calls need to be recorded, including names, dates, and content, as well as any other points of communication, including in-person meetings. Doing so contributes to the consistency of your overall practice, and is necessary for compliance reasons.
- Use correct error processes - We all make mistakes, and you need to make sure that when you do, you have the right correction system in place. If you make an error, simply draw a single line through the entry, and sign off on the information. This way, others can see the content of the original mistake, the correction, and who documented it.
- Don’t alter or delete notes - Altering or deleting notes is a big no-no, and should be avoided in every possible situation. It is best to record everything at the time, because as the saying goes, ‘if you didn’t write it down, it didn’t happen.’ Memory is fragile and susceptible to many changes, so with each record, write as much information at the time, as adding later can change the timeline of what occurred.
EHR: It’s meaningful use
One of the greatest tips concerning medical records management is transitioning to electronic health records (EHRs). EHRs allow you to be HIPAA compliant with all policies and regulations, without having to worry about the nitty-gritty details. In addition to this, you can rest easy knowing your patient data is highly secure with bank-level encryption embedded in the software.
Many healthcare businesses, such as Carepatron, design such software with healthcare professionals in mind, and work towards helping you elevate the quality of your practice. With medical record resource management incorporated into its use, you can guarantee efficiency that will drive the success of your clinic.