1.9 Patient record management

What is patient record management?

Patient record management refers to a system responsible for governing patient information throughout the entirety of the data lifecycle. From the moment a patient record is created, it must be appropriately stored, secured, and maintained. Is a collection of clinical information. Electronic patient records are typically saved to a hard drive in one central location, and from there the server shares access to healthcare professionals. Digital systems offer a fully integrated solution for healthcare companies so they can properly communicate patient details across primary care (hospitals and surgeries) or secondary care (child, community, and mental health) but they also allow healthcare professionals to contribute to the record’s upkeep and use the most accurate information as part of a patient’s assessment and treatment.

Why is it important?

1. Increases the Ease and Efficacy of Clinical Decisions

When doctors have access to patient records when they need them, they are able to make better decisions regarding disease management. Fast, convenient access to records also means doctors spend more of their allotted visit time speaking directly with the patient for a higher level of patient care. Especially in emergency situations, having a clear clinical picture of the situation at hand can advance care coordination, reduce the possibility of unnecessary procedures and tests, and save money for both physicians and patients overall.

2. Allows for Safe Exchange of Information

Doctors and other members of a patient’s care team may have the need to exchange clinical records in order to make smarter decisions about the direction of care. However, most — if not all — information in a patient’s record is sensitive and personal, requiring strict compliance to HIPAA and other pertinent data privacy guidelines.
A comprehensive DMS not only puts strong cybersecurity protocols into place to protect archived records, but it also helps physicians share necessary patient details safely. Automated monitoring and the ability to track and control document access are key ingredients to a more secure environment for all your medical

3. Provides for Higher Level Patient Care

Improving the patient experience is at the forefront of priority for modern healthcare organizations, an initiative which dovetails neatly into better patient care. Reducing reliance on paperwork by using digital document management allows doctors to spend more time with patients to better manage their concerns.
Digitizing medical documents also reduces the potential for human error, a problem that can often result in costly and hazardous medical mistakes. In fact, medical errors are currently the third leading cause of death in the United States. Well-organized and accurate digital documents reduces the risk of miscoding and errors, further reducing your organization’s risk of lawsuits and improving your ability to serve your patients’ highest good.

What are the components of medical record?

The answer isn’t necessarily that simple, everyone in fact has a unique record, some with far more information than others. Doctors are all different and take notes in their own style, so medical records can greatly depend on the medical staff that created them. However, some unified components exist in nearly every complete medical records.

-First of all the patient demographics data, which are patient’s basic information such as the name, the date of birth, extending to social security, state, or government-issued identification number.

-Social screenings: as early as the year 2000, the American College of Obstetricians and Gynaecologists (ACOG) had developed an educational bulletin on perinatal screening and intervention for psychosocial risk factors including barriers to care, frequent moves, safety, food insecurity, substance abuse, partner violence, stress, and unintended pregnancy. The College considered that addressing psychosocial issues is an important part of improving health, that screening should be performed regularly and documented in the patient medical record, and that an effective system of referrals will increase the likelihood of successful intervention.

-Information about their their genetics : a patient’s family medical history plays a vital role in their health. Some health issues and concerns are genetic, which makes them important additions. While most family health problems aren’t anything to worry about, some cancers and other hereditary diseases can be passed down. So, a family medical history, if accessible, is often part of a person’s medical records.

-Medical history and diagnosis received so far: Everyone has a medical history, even people that have never been to a hospital or seen a doctor, it turns out in fact, by not having a medical history is considered a medical history. However, the majority of people do have some form, small or large, of medical history. This history could include past and present diagnosis, medical care, treatments and allergies. Even the absence of a need for medical care is in a patient’s medical history. This information paints a picture of a patient, identifying which ailments or illnesses are acute or chronic, possibly situational or even seasonal. What a patient ingests or otherwise takes that could affect their health is also a part of their medical record. This medication history can include prescribed or over the counter medication, herbal remedies, or even illegal substances that they have at one time used. Some of this information is gathered from patient testimony while others may come from past doctor prescriptions that are already on file. A patient’s medication history can also help paint a picture of their health along with possible complications that have arisen since. For instance, some medications don’t play well with others and can make symptoms worse or cause new symptoms to occur.

-The final two pieces of information that play a vital role in a person’s medical records are their treatment history and medical directives. A treatment history should encompass every treatment that has been given, including the efficacy of the treatments.

The following should written on the medical record folder:
-Patient’s name
-Patient’s medical record number
-Year of last attendance

All these components allows the patient greater freedom in the choice of treatment and give a great support in:
E-prescriptions: With the pandemic raging from time to time, patients are more worried about their health now than ever before. They prefer scheduling appointments online with their doctors as they do not want to step out and risk their health unnecessarily. As a result, electronic prescriptions nave become ver popular.
How does it work? The EH software is fed with electronic prescriptions that make it easy for doctors to prescribe medicines to each individualy patient through the software itself. What's more, the patient can send this to their pharmacy and collect the medicines when they are available. Alternatively, many hospitals with pharmacies within also deliver the medicines at the patients doorstep. Hence, hospital management software is extremely useful to hospitals.
Lab interfaces: Lab results help doctors in making accurate decisions to provide the best possible healthcare to their patients. EHRs are highlv useful in storing these lab results. Through the EHR software doctors can directly request for reports in various formats. Once they view it they can pass it on to the patients along with their suggestions
Clinical support: by sending alerts and reminders about tests and examinations to patients under constant supervision. doctors can check-in with them periodically. The software can be programmed for each patient individually.
Billing function: By integrating features of the accounting department into the software, the billing functions can be taken care of too. Through APIs and payment gateways, the system will be able to process payments through various methods such as cash. card. online transactions, etc.
Generate data reports: EHR software has more uses than just scheduling appointments, keeping track of inventory and collecting data. One of the key functions of the software is analytics. Through the data reports generated by the software, healthcare facilities can easily analyse both their clinical as well as financial performances. Every healthcare facility needs to generate these two types of reports:
Admin process report: Through this report, the facility can analyse the productivity of the processes in their institution such as billing, patient care, time management, scheduling of appointments, etc., and improve upon them.
Health assessments: This report helps medical facilities in an area to determine the general health of the population. Through various healthcare and vaccination drives, these facilities strive to increase the population's health while keeping viruses away.

Types of records :
One of the most effective strategies for avoiding medical errors is gathering accurate patient data and making the patient a partner in their care.
You can collect patient data in several different ways —

  • Paper-based medical records
  • Computer-based medical records

Advantages of Computer-Based Medical Records
●More than one person can use the record at a time.
●Information can be accessed in a variety of physical locations
●Records can often be accessed from another city or state
●Complete information is often available in emergency situations.

 Disadvantages of Paper-Based Medical Records
●Only one person can use the record at a time, unless multiple people are crowding around the same record.
●Items can be easily lost or misfiled or can slip out of the record if not securely fastened.
●The record itself can be misplaced or be in a different area of the facility when needed.

 Types of organization of medical records

 Source-oriented records

●Traditional method of keeping patient records
●Observations and data are cataloged according to their
●Forms and progress notes are filed in reverse chronologic order.
●Separate sections are established for laboratory reports, x-ray
films, radiology reports, and so on.

Problem-oriented records

Divides records into four bases:
1. Database
2. Problem list
3. Treatment plan
4. Progress notes

Retention of medical records

Medical records should be stored securely and kept confidential at all times, including during transfer between clinics or hospitals and when the consultant needs to sent patient date t a secretary. They need to be protect against accidental loss, including corruption, damage or destruction.
Healthcare providers and individual physicians are required to keep medical records for a period of time, as defined by the law in their country. There are different parameters that may affect the requirement to retain medical records:

1)The frequency of visit: the less frequently the patient visit their caretakers, the longer they may have to keep records;
2)The insurance contracts: third-part payors may have their own contractual requirements to retain medical records;
3)The statute of limitation: for example in the USA there is a final date by which patient must file a lawsuit and until such time the patient’s record must be retained;
4)The state law: physicians operating in different states may be subject to medical retention regulation regulations from one or more state.

In addition to these parameters there are others that affects the period of time in which patient’s data must be kept. The retention depends on the age of the patient:

-For children and young people the records must be kept until the patient’s 25th birthday or 26 if the young patient was 17 at the conclusion of treatment.
-For the maternity records the time of retention is 25 years after the birth of the last child.
-The records of a mentally disordered patient must be kept for 20 years after the last treatment.
-The records must be kept for 8 years after the patient’s death.

Confidentiality of medical records andrespect of privacy

With the increasing computerization of medical records and the consolidation of the consolidation of the health care system, people have become more concerned about the potential threat to the confidentiality of individual health information. The biotechnology industry and the health community believe that is of paramount importance to provide strong protections for sensitive patient health information. People privacy can be protected by utilizing coding and encryption technologies, by security laws and careful restriction of the codes and by strong penalities for unauthorized use of any such code or the encryption device or reveal the individual’s identity.

Privacy is one of the fundamental things in the field of medical records. The system employees pledge to keep medical record information confidential and to respect privacy. A medical record or information contained in a medical record can’t be given to other people. These should be released only if there is a valid written consent for the release of this information is obtained from the patient or legally authorised representative.
The only people who can access to health information are:

1)Patient himself;
2)Family physician;
3)An authorised person by the patient;
4)In case of death the only people can access are authorized representative of family or legal representative of the deceased.

Role of staff manteining confidentiality

Medical record department personal are advised to:

1)Acknowledge request for health information promptly
2)Mantein integrity of records
3)Take responsable steps to confirm the identity of the person seeking the information
4)Assess the information to determine whether access to it must or may be denied

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