Medical record – keeping is vital in healthcare. It helps hospitals and clinics optimally care for their patients. One of the most reliable methods to help resolve incomplete medical records is to hire a well-reviewed medical transcription company to handle such paperwork for your business.
In this blog, we will explore the consequences of poor medical record keeping and how your organization can do it right.
Importance Of Medical Records
There are countless positive benefits to maintaining proper medical records. They help doctors and medical staff:
- Analyze treatment results on time.
- Make a thorough diagnosis.
- Comprehensively evaluate patient profiles.
- Accurately plan treatment strategies.
- Perform proper billing protocols.
- Ensure healthcare professionals are protected in cases of alleged negligence.
These are powerful points favouring the routine maintenance and updating of medical records.
Consequences Of Incomplete Patient Records
Improper maintenance of patient documentation can result in serious or stressful consequences for any healthcare establishment.
By failing to maintain a detailed ‘story’ of your patient, or by maintaining unclear or non-specific databases, healthcare companies will only end up putting their own patients’ lives at risk.
Remember, if it isn’t documented, it never happened. This slogan is a simple and effective way to understand the importance of medical record keeping and what might happen otherwise.
Errors In Medical Record Keeping
CERT-like audits have stated that insufficient documentation mistakes often include the following:
- Missing or incomplete signed progress notes or orders that declare intent for any provided medical services.
- No provider signatures or illegible versions of them, resulting in unauthenticated medical records containing no valid attestation or signature log.
- Electronic signatures that do not follow proper electronic record policies for the same.
- Any and all incomplete or incomprehensible progress notes, including lack of proper dates and patient-specific timestamps.
By maintaining healthy medical records, your company will not only help its patients but also stay compliant with state/national policies and laws.
Consequences Of Bad Medical Record Keeping
Some of the main consequences of ill-maintained medical records include:
- Loss of license for the physician involved.
- Unreliable or ineffective patient care.
- Wrong treatment-related decisions.
- Lost reimbursements and/or revenues.
- Dangerously inaccurate data entries about patient care.
- Inappropriate billing that could result in serious fraud charges.
- High (and avoidable) expenses related to diagnostic studies.
- Unclear communication among referring physicians and/or medical consultants, resulting in poor treatment plans or inaccurate evaluations.
What Should Good Medical Records Have?
Remember, incomplete medical records mean incomplete care. Quality medical records need to be clear and accurate about everything pertaining to a patient, including any complaints they may have had from the beginning.
Here are some key elements that all good medical records must possess:
- Patient diagnosis and initial impressions (if any).
- Patient demographics.
- Recommended date for return visits.
- Reasons for current visits.
- Drug allergies (if any).
- Exam results, including positive markers or any abnormalities.
- Scope of a patient’s medical exam.
- Any educational or instructional information given to a patient.
- Crisp and clear management plans and agreed-upon activities.
- Any and all medicines that were prescribed, administered, and/or renewed.
- Documented communiqué with the patient’s family and/or friends.
- Complete treatment plans and any future recommendations for the same.
These and other entries need to be recorded in a timely manner. A hospital processes so many patients every hour of every day that it can get overwhelming to maintain large amounts of information in a short period of time. If any delays do happen, that too should be recorded for future use by other medical staff members.
Best Practices For Medical Record Keeping
Some of the most essential ways to maintain reliable medical records are to routinely train or educate your hospital staff on the following points:
- Keep the comments objective and accurate.
- Clearly state any objections in case management.
- Ensure non-compliance gets documented.
- Note down all informed consent.
- Mention any oral communications.
- Leave no blank fields in medical charts.
- Convey all aspects of a patient’s medical history.
- Include details about prescriptions and refills.
Any hospital staff involved in medical record keeping needs to add their respective names and designations in clear writing or font so there are no legal misunderstandings down the line.
How To Improve Your Healthcare Establishment’s Medical Record Keeping?
Here are 4 proven points to further guide your strategies and plans to create and maintain a wholesome medical record for your healthcare organization, hospital, or clinic.
1. Improvement
Address any identified opportunities to improve medical documentations. Involve the provider and use compliant queries to achieve this aim.
2. Patient Safety
All patient safety indicators need to be identified in your medical records. The same applies to hospital-acquired safety conditions. If needed, the record can also note if such conditions were present when the patient was originally admitted.
3. Education
Select clinicians and medical staff can benefit from intermittent educational opportunities about accurate medical record keeping. It will improve healthcare practices and service quality overall. Moreover, the staff member’s medical profile and patient care in general are also enhanced thanks to complete documentation.
4. Reviewing
Regularly review all patient-related medical records. This will help you spot insufficient, incorrect, unclear, or irrelevant documentation and diagnoses.
Conclusion
There are numerous ways you can maintain proper medical records for your healthcare establishment. This decision will benefit all your patients. In addition, good medical records will keep your practice compliant.
With accurate and complete medical record keeping, you will improve patient safety, health care provider service quality, and business’s reputation over time.
Reach out to the MedzLegal team to learn how you can improve your current medical record keeping – systems. You can also call us if you want to create a brand-new medical documentation strategy for your healthcare company.
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