Medical records refer to the collection of a patient’s basic health information. This includes a history of all the past and present illnesses they’ve gone through and the corresponding treatment. These records are important, so there can be a smooth flow of information regarding the current needs of a patient. For the best care to be given, these have to be seen in totality from the past, and not just the present condition.
Maintaining Medical Records
Doctors generally have to keep patient records by themselves through their secretarial team. However, a hospital will also have a separate medical records department where all these information is kept. Whichever way, it’s essential to capture medical records with clarity to ensure proper handling of confidential details.
With technology, gone are the days when medical records were kept only through physical ways. Now, there are many different things you can employ to make better record keeping.
Here are some of the important tips in having efficient medical records:
1. Separate Information By Tab
If you have an electronic record system, then group similar information for every patient by a tab. If you also have a backup physical records system, the information can be grouped by folders or binders.
Every patient may have a long list of medical history, depending on when they started seeing a doctor. It’s helpful to group into like information, so it’s faster to locate what you’re looking for.
Some details that could be grouped are:
- Test And Laboratory Results
This pertains to all tests the patient has undergone, even minor laboratory results or blood work samples.
- Current Medication
This includes the names of all medicines taken, date, dosage, and purpose. This information is helpful for doctors to decide on which medications would work the best for a patient, and which ones they may have had severe reactions to.
This refers to up-to-date information on shots children and adults have. This is needed especially for school records as many require their students to have certain vaccines done.
This would comprise all allergic reactions patients have from seasonal allergies to food and medicines.
- Ongoing Treatment Or Injury
This should include hospital discharge orders and other related documents, medical bills from healthcare providers, test results, and insurance claims if any.
2. Use Apps And Online Websites
There are now many apps and websites you can utilize to keep personal track of medical records. This will make it easier for you to track records from multiple sources and also keep them up-to-date.
When you make use of apps and websites, you have an opportunity to create backup files of the paperwork itself. Just in case your physical files get lost, you don’t lose track of your medical history. This is also a proactive approach as you can compare your records with the doctor’s, in case there’s anything you’ve missed out on.
This makes you more efficient in keeping medical records as they’re all in one place, and you can bring them with you all the time anywhere. This can come in handy, for instance, if you’re traveling and you meet an emergency. At the hospital, you’ve got your medical records with you to present to the doctors and not be stressed about remembering pertinent details on your own.
3. Protect Against Data Breach And Identity Theft
Whether you have a physical records system or an electronic one, it’s important to be protected against data breach and identity theft. Expert hackers are right around the corner, looking for victims to prey on. Generally, these medical records are stolen to make false claims from insurance companies and government pensions, for instance.
With electronic systems, you can employ certain codes or safety measures to ensure only the patient can access saved information. As to physical records, if you work for a doctor and you’re tasked with keeping medical records, be sure you master all legal rules applying to the release of any sensitive and personal medical information.
Every time you visit a doctor, even if it’s only for minute reasons, there’s always someone in charge of recording significant details about your health. This is important so no pertinent information about your condition is missed.
If the records department doesn’t have an efficient system in place, this could mean lost records or proper care won’t be provided. If you’re a medical practitioner or employee working along this line, these tips are good to consider, so you can work towards better handling medical records efficiently and effectively.