Tips for accurate, secure Patient Record Management

Managing patient records effectively is a crucial aspect of owning and operating a healthcare business practice. With efficient patient record management, you can ensure a high standard of care when it comes to your patients, and focus on clear communication with fellow healthcare professionals. Considering that good patient record management accounts for almost 40% of effective healthcare operations, understanding how to maintain and sustain good systems is a must.

Because patient records reflect you, as the practitioner, and your medical reasoning, it’s important that they are to a high standard. They provide a snapshot of the current state of the patient’s health, as well as providing a place for you to defend any complaints or clinical negligence claims. Others also need to be able to easily view and assess your recorded information, and with the right tips, you can easily execute effective patient record database management.

Patient records are of utmost importance within the healthcare workspace, due to a multitude of reasons. 

Given that they hold highly sensitive and confidential information, it is paramount that records are secure. Personal information concerning contact details, as well as medical health concerns, are usually stored within electronic patient management systems, which could be jeopardized without the proper safety protocol. Having secure patient records is vital to minimize the risk of hacks or information leaks.

Protecting patient records means that they can be effectively shared between healthcare professionals when needed for review and assessment. As a result, the records also have to be clear, legible, complete, and highly accurate. Doing so will enable highly productive communication, as well as building trust between practitioners and their patients. Highly secure records that contain up-to-date information will facilitate better continuity of care and more accurate clinical decision making.

To ensure that you follow medical record procedures closely and to a high standard, it is important to consider the variety of policies under the HIPAA enactment. 

• Medical records security & medical records storage - There are some universal security measures that you must follow if you want to be in compliance with HIPAA. Firstly, you must be able to identify and protect against any anticipated security threats. In addition to this, you must have the right software and hardware systems in place to monitor who can access  what information. There should be restrictions in place regarding who has access to records, and your staff need to be trained so they know how to effectively manage the 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 are only to send patient records if they have permission to do so. The Fair and Accurate Credit Transaction Act (FACTA) supports these systems by reducing consumer fraud and identity theft risks through restriction of release. Insurers can only share medical records with affiliates.
• Data destruction - This process involves destroying information to prevent it from being used for illegal or unauthorized purposes. Considering that many medical health records are kept within electronic patient record software and electronic patient management systems, this is especially important. HIPAA and FACTA standards have strict protocols on how to properly destroy data, such as shredding paper records with burning or pulverization until it is illegible. Electronic records need to have overwriting software or have 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.

As a top tip - to help you with medical compliance with policies and procedures, you may find using patient notes software easiest. They’re becoming more and more commonplace, and it is an efficient way to manage records whilst maintaining security.

For the best medical records management, consider incorporating the following tips:

• Have clear entries - Your records need to be legible so other healthcare professionals can understand the content when needing to review or assess the respective patient. Try to avoid abbreviations, and use specific, objective, language. Any errors should be transparent and signed so others know who made the mistake. 
• Make sure it’s up-to-date - Patient findings, tests, diagnoses, history, and treatment should all be current and in chronological order to show continuity of care. This also includes contact information such as email addresses and phone numbers. If you feel you’re including too much, it’s better to err on the side of caution to avoid missing out on any critical details.
• Train staff - Make sure your staff are regularly trained so they know how to manage patient records. If you are using an electronic record management system, then there is even higher importance for you to ensure that healthcare personnel know how to use the software. Continuous education and training resources may need to be provided to achieve this.
• Automate - One of the easiest ways to execute a highly efficient medical record management system, is to select software that can attend to your needs. Using patient record-keeping software can help reduce time costs by a large margin, as well as improve accuracy and protect patients. Patient health record software is one of the safest ways to provide medical records that can be backed up with remote data storage and can ensure that only authorized persons are accessing their content. 
• Self-audits - To protect patient privacy, one of the best ways to remain compliant is to monitor and double-check all performance measures, as well as client information. Continuously evaluating information as it is recorded is a highly efficient process that increases HIPAA compliance. 
• Label records - Ensure that every record handled is monitored and labeled so it can be efficiently retrieved when needed. 

Final thoughts

Patient record management should be a top priority in your healthcare practice, and ensuring that patient data is highly secure will allow for a higher quality of care in your clinic. Not only this, but to be compliant with HIPAA standards and policies, you need to consider the role of what it means to have effectively managed medical records.

To make this process easier for you, many healthcare businesses, such as Carepatron, design electronic patient record software for you to protect sensitive patient data. That way, you do not have to be concerned with always researching FACTA and HIPAA laws, and security walls are already in place, such as bank-level encryption, to prevent any potential security breaches. Authorized healthcare professionals can have easy access to the patient data as required, and you can ensure a high continuity of care.

Further reading:

• Guide to Privacy and Security of Electronic Health Information
• The U.S. Healthcare System: A National Perspective