Understanding Health Records 101

Electronic medical records refer to a collection of data relating to a patient’s medical information that is stored electronically. This may include diagnoses, medication, immunization, allergies, and treatment plans. Electronic health records can be shared between different healthcare providers to ensure that their patients are being treated accurately. Storing medical records electronically is a significantly more common method than storing them hard-copy, and in 2017, nearly 9 in 10 office-based physicians used an EHR. Storing healthcare patient records securely is an integral part of working in the healthcare field, so ensuring you select the right EHR software is an important task. We’re here to provide you with a brief overview of the different types of information included in patient records, and point you in the direction of selecting the perfect EHR for small practices.

Before medical data was stored electronically, patient information was recorded in a medical chart. Medical charts are composed of all of the relevant medical events that have impacted an individual since birth. This includes surgical history, medications, allergies, immunization records, obstetric history, habits (alcohol consumption, sexual history, smoking), and medical encounters. The medical chart can be referred to by physicians before meeting with a patient, so they are aware of the best way to treat them. The medical chart also contains information provided by physicians following an appointment with a patient. This includes the chief complaint of the patient and relevant symptoms, medical examinations and results, assessment, treatment plan, and progress notes.

Electronic health records help regulate medical charts and ensure that they are accurate with no important missing information. EHR software can alert the medical practice to areas of missing information in order to complete a patient’s records. When appropriate, it can be shared between other medical providers, including imaging departments and facilities. EHRs can be thought of as an electronic version of a patient’s medical chart that is securely stored and can never be lost. 

Importantly, EHRs belong to the patient. It is their medical information, and they are the prime authorized user. They can grant their healthcare providers or other third-parties access to their EHR, and this frequently occurs. EHRs are a fantastic software when it comes to managing patient data, and they consistently improve healthcare.

Electronic health records have several important functions. They are shared between healthcare providers to ensure continuity of care, effectively track the progress of patients, and can be requested by third parties in the event of malpractice. Given their importance, it is critical that your healthcare practice is reliably producing accurate patient records. We have collated some key strategies to help you and your team manage your clinical documentation:

• The sooner, the better: The information contained in your clinical notes needs to be accurate. The best way to guarantee accuracy is to write your needs after every session. This way the session will be fresh in your mind, and you won’t miss any key information. 
• Complete: EHRs are highly effective at noticing missing information in your patient records. If you are notified of these fields, it is in your best interest to complete the missing data as soon as possible.
• Clarity: Clinical notes can be, and often are, shared between other third parties, including other healthcare providers, insurers, and lawyers. They need to be written as clearly as possible, which means your language needs to be easily understood. Abbreviations that aren’t universal should not be included, and you should avoid vague or unnecessarily wordy language. 
• Legible: Another aspect of ensuring your clinical notes are clear, is making sure they are legible. Some clinicians prefer to hand-write their notes, which is perfectly fine as long as their writing is legible. We recommend using clinical note software. It is a guaranteed way to ensure legibility, and can easily be integrated and stored with other patient data. ‍
• Errors: When a mistake is made, it is important that you follow the right procedure. Written mistakes should be crossed out with a single line so that the original word is still visible. You should sign these with the date, time, and your signature. Online notes have an audit trail, so every entry and deletion can be viewed. If there has been a deletion, it should be clear to the viewer why you made that decision.

The use of electronic health records in different healthcare practices reflects the growing application of advanced technology in medicine. EHRs are real-time records that grant authorized users access to key patient information. Utilizing this form of healthcare documentation goes beyond the typical clinical data that is collected by physicians. Some of the advantages of using electronic health records include:

• Patient care: EHRs facilitate faster access to patient records allowing for more efficient patient care. They integrate with technology from other facilities, including labs and other EHRs. Patients can benefit from having e-prescriptions sent to pharmacies, not having to fill out forms at medical clinics, and access to online referrals.
• Patient communication: EHRs offer a streamlined avenue of communication between patients and physicians. This allows patients to reach out to physicians with questions or concerns and encourages physicians to be more proactive in communicating with their patients.
• Care coordination: Many medical clinics find it difficult to manage the coordination of care, especially if a patient is transferred between departments or facilities. EHRs ensure that all medical facilities can access real-time patient information. The availability of patient data reduces unnecessary tests and the number of errors that occur during treatment.
• Reduced costs: EHRs can help your practice save money, by eliminating the need to pay for manual data entry. This has the additional benefit of leading to more accurate and efficient patient charts.

EHR implementation strategy for your healthcare business

The process of EHR implementation can take time, and you will want to make sure you select the right software for your healthcare business. We have broken down a general guide that indicates exactly what the process of implementation can look like:

• Plan: Planning is always the first thing to do when you are changing something in a business. Your plan should outline all of the steps you are taking to implement your EHR software.
• Select a committee: There are various aspects of EHR implementation that will require someone to oversee them, and these roles will include a project manager, data analyst, and a nurse and physician advocate.
• Budget: Your budget should be thorough and realistic. If you expect to spend slightly more than you originally planned for, you will be more likely to stay under budget.
• EHR implementation: The actual implementation of EHR into your software will take a long time. Make sure you have scheduled the various necessary steps.
• Data integration: You will need to transfer the patient data your clinic has stored into the database of the EHR. This process can take some time, as not only does it need to convert paper records into electronic records, but it organizes, cleanses, tests, and verifies this information. 
• Staff training: One of the most commonly overlooked steps of integrating EHR software is staff training. Some of the most efficient EHRs are unsuccessful due to mismanaged use. Organize a training program to ensure that all of the employees at your healthcare business can effectively use the EHR software.

A further consideration when implementing EHR software is deciding what application to use. Carepatron offers a fully integrated secure platform with excellent EHR and clinical documentation capabilities. It is HIPAA-compliant and allows you to store all of your clinical notes on one secure platform. With Carepatron, your business can streamline various time-consuming tasks, boosting productivity and saving both time and resources. 

Further Reading:

• Social Determinants of Health 101 for Health Care‍
• Making EHR Safety Reporting Easy