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13 Signs of Exceptional Patient Record Keeping

by GMDP October 10 2021

If you are a physician, you surely know that information is important to your practice. To be entrusted by your patients to deliver the best care possible is impossible to achieve that without having an efficient way to keep the records of your patients.

 

Every single day healthcare providers and staff are managing multiple patient records. They deal with it every day from registration forms, billing forms, insurance forms, medical forms, and much more. Patients are usually the ones who fill up and submit forms and healthcare facilities are in charge of keeping these documents safe.

 

This is why having a good patient record-keeping system is important. Good management of a patient's record captures the most efficient way to record, store and organize records may it be paper or electronic.


When a healthcare facility’s record management system is exceptional, it can enhance the way they deliver patient care. Here are eight signs to check to know that you are on the right track with your patient record keeping process:

 

  1. Increased Productivity

 

When healthcare facilities practice good records keeping, they can use the time used to search for patients' records. When documents are transformed into electronic form, like the Electronic Medical Records system, with the use of various search terms, looking for documents will be much easier. When looking for records is done easier and faster, healthcare staff will have more time to spend on other value-added tasks

 

  1. Reduced Human Error

 

A cluttered desk can produce a cluttered mind as well. Although, mistakes can not be 100% avoidable yet too many paper files can make mistakes even worse. When there are a lot of documents to be sorted out and with no system to follow, losing or misplacing files will most likely happen.

 

A proper document management system increases patient safety and also protects healthcare providers from potential and legal sanctions.

 

  1. Heightened Security

 

A good record-keeping system should also enhance the security of documents Most healthcare documents contain, especially those containing sensitive information that can have destructive effects if broken, misplaced, or lost.

 

Access can also be regulated among personnel. Healthcare staff will have the ability to control who has access to the documents. Document security is important to every healthcare provider because it is their responsibility to protect sensitive information.

 

  1. Easier Collaboration

 

To reduce duplication documents can be retrieved and also modified by some users while for others access is denied. Collaboration features in the Electronic Medical Records system allow multiple users to view and edit documents at the same time.

 

Documents captured from different sources can be accessed from various locations. A good record-keeping system allows healthcare staff collaboration that will provide better workflow monitoring.

 

  1. Better Backup and Disaster Recovery

 

When a facility has a good management system, files will be stored easily and much safer. It is also important to keep in mind that part of the management solutions in every business is to have a backup plan for unexpected disasters.

 

When the storage of data is familiar to the healthcare staff, even during emergencies, the tracking and retrieval of these documents will be much easier.

 

Given the importance of patient records and documents and the benefits on why organizanising these records are very important, the question lies in, How? How can we efficiently manage patient’s records?

 

  1. Easy identification of what needs to be in or out.

 

All information is important in the learning process of any company. However, it is important to know what documents need to be kept and what ones need to be tossed out. 

 

In keeping the needed documents, it is important to keep the details legible and easy to understand. It will also help a lot of physicians will make an outline of their clinical notes. Always keep in mind though to not write scribbled notes that you do not want the patient or other physicians to read.

 

Some of the information you need to keep are patient history, examination findings, diagnoses, management plan, and details released by the patients to aid his/her treatment.

 

  1. Efficient record and track Inventory

 

To have an effective records-management program, auditing every piece of document and also electronic file in your organization is very important. The rule of thumb is knowing what records you currently obtain before you come up with a records management plan. 

 

Document mismanagement and lack of an effective record-keeping system are key contributors to poor workflow in healthcare facilities. When documents are not tracked and they go missing or are unaccounted for it may lead to serious legal problems. Missing documents are easier to track when they are recorded.

 

  1. Prioritized security and privacy

 

When the security is lenient, the data is more prone to breach. Every business should prioritize the security and privacy of their client’s information, in healthcare, it is more crucial to keep the confidentiality of your patient’s records.

 

A date leakage may lead to a huge problem. Monetary and legal. Building your patient’s trust is hard but very important. And if your facility has a bad record in confidentiality, patients would not entrust their information and much more their health in your hands.

 

Companies should ensure that sensitive information can only be accessed by specific persons with permission. Electronic Medical Records will assist and track the safety of patient’s information

 

  1. Digitized Paper Records

 

Digital Innovations such as Electronic Medical Records and Electronic Health Records are making record-keeping more efficient and easier. One common misconception is that digitization of paper records can be time-consuming and costly; however, the benefits will far outweigh the initial cost and effort.

 

Healthcare providers will surely benefit from improved operational efficiency and easier access to information and data, significant savings in storage costs, reduced risk of losing paper records should there be natural disasters.

 

  1. Developed Procedures for Inactive Records

 

Even if the healthcare industry needs every information that they need, some information also has an expiration date. Records should be evaluated regularly to transfer to the archives storage for safe-keeping.

 

Just like online records are vulnerable to data breaches, physical records and documents can also be prone to leakage. Considering also the fact that some data are to be kept indefinitely and some should be destroyed after usage.

 

Disposal of inactive and irrelevant data can also prevent the spread of misinformation. Healthcare staff no longer need to find information even in documents made years ago.

 

  1. Up-to-Date Information

 

Always includes relevant matters associated with patient’s care, such as patients’ history, medical findings, diagnoses, treatments, and advice is given. A patient’s medical record is also highly encouraged to be updated regularly and in chronological order. This is to give proof that there is progress checking and constant patient care.

 

Another rule of thumb is to be careful to include too much information in your patient’s medical records rather than too few, as an old saying goes, ‘If it’s not in the record, then it didn’t happen.

 

  1. Involved Staff in Efficient Record Keeping System

 

It is important to regularly train your staff in recordkeeping since it is a vital process in every business. Record keeping such as recording on paper or using Electronic Medical Records or EMRs to capture important healthcare information.

 

To keep your system relevant and modern, it is important to improve your recordkeeping system by constantly reviewing it. Make sure to check elements and the effectiveness of information processes. It is also the responsibility of healthcare providers to audit the performance of the record-keeping system to determine the areas of improvement.

 

  1.  Accurate Medical Transcription Service

 

One key factor of a good record-keeping system is the accuracy and legibility of medical notes. The Electronic Medical Records system has the feature of dictating your notes into a voice recorder or mobile device. Physicians can then email or voice stream them to a transcription service, often based in the cloud, for more accurate transcription and storage of notes.

 

Thankfully, Electronic Medical Records in the Philippines are rising and Philippine physicians can now have an easier time transcribing important notes.

 

Takeway


Efficient and improved record management is one of the greatest ways to increase the productivity of a healthcare facility. When the record-keeping system is streamlined and efficient, healthcare staff spend less time searching and managing documents and more time on high-value tasks.

 

It’s time to get your documents properly managed and under control.


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