Guide To Managing Medical Records Better

Medical records are an integral part of every healthcare business, and if managed right, they can significantly boost the quality of care in your practice. Precise medical records management allows fellow healthcare professionals and clinicians to quickly review and assess patient information when needed and accurately understand patients’ conditions.

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Understanding the concept of medical records in healthcare

Understanding the concept of medical records in healthcare

Medical records are an integral part of every healthcare business, and if managed right, they can greatly boost the quality of care in your practice. Clear medical records management allows fellow healthcare professionals and clinicians to easily review and assess patient information when needed, and gain an accurate understanding of patients’ conditions. 
Your patients can also have ease of mind in knowing that their private information is in good hands, and that it is up-to-date, secure, and reflects their current health status. The patient experience accounts for almost 80% of the medical experience, and so having accurate medical records in healthcare means your treatment can be more effective in addressing the direct issues at hand.

What are the main characteristics of good medical documentation?

To succeed in creating and maintaining a high standard of medical documentation, there are five main standards that you need to adhere to:

  • Accuracy - To achieve good medical record management, you need to ensure that your records are highly accurate in the information they present. This means minimal mistakes, and they need to actively reflect the state of your patient’s health condition. A patient should be able to read it and agree with your descriptions.
  • Accessibility - Only authorized persons should be able to access certain information, and this also extends to beyond the patient. Access should be restricted to the patient or a designated representative. 
  • Comprehensiveness - Medical records should be legible, free from mistakes, and contain objective language. Remember that other healthcare professionals may be reviewing the content of your records, so it is important to make sure they can be universally understood. 
  • Consistency in medical communication - What you are writing needs to be consistent with medical records from other practices and clinicians. For example, if you see a patient with depression, and another practitioner sees a patient with the same symptoms but is diagnosed as something else - then you need to reevaluate through communication. Results need to be consistent to ensure you are truly representing the patient.  
  • Updated information - Information needs to be up-to-date to highlight the current condition of the patient. This means higher continuity of care, with a higher standard of treatment, as you can directly address symptoms that are being presented. 

If this overwhelms you, clinical documentation can be made easy with the help of software. Online healthcare platforms are a great way to ensure you meet these five criteria with ease.

What are the main characteristics of good medical documentation?
Medical records policy and procedures under HIPAA

Medical records policy and procedures under HIPAA

For effective healthcare records management, you need to consider the following policies and procedures to comply with HIPAA standards.

  • Medical records security & medical records storage - You need to identify and protect against any potential security threats as well as implementing the right software and hardware systems that monitor the accessibility of information. There should be limited access regarding who can view and retrieve certain data, and your staff need to be educated on how to effectively use these storage systems. 
  • Medical records access & release - Only the patient or a designated representative has the right to access medical records. If a provider or insurer needs information, they can only send patient records if they have permission to do so, as they are permitted to share records solely with affiliates. To aid this process, the Fair and Accurate Credit Transaction Act (FACTA) helps reduce consumer fraud and identity theft risks through restriction of release. 
  • Data destruction - This process involves destroying information to prevent it from being used for illegal or unauthorized purposes. This is done by adhering to a specific protocol, such as shredding or burning paper records until it is illegible. Electronic records need to have overwriting software or magnetic methods to destroy hard drives.

Retention timelines - There are also specific laws concerning the length of time as to which medical records need to be kept. This differs in each locale, but you need to research and implement these protocols into your practice.

Tips to manage medical records better

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. 

Further reading:

Tips to manage medical records better

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