Table of Contents
- 1 Overview
- 2 What is Medical Documentation?
- 3 Why is Documentation Important in Healthcare?
- 4 Medical Record Management
- 5 Why Should You Keep an Accurate Medical Record?
- 6 Electronic Medical Records (EMR)
- 7 Electronic Health Records (EHR)
- 8 Retention Time in Medical Records
- 9 Can we Request Medical Records?
- 10 How to Request a Medical Record?
- 11 Medical Documentation and Medical Record Review
- 12 Tips to Avoid Errors in medical Documentation
- 13 Conclusion
Here is a riddle for you. I am not your parent or guardian. I am not your caregiver. But I have all the details about your health. I will travel with you throughout your life. Who am I? Can you figure out the answer? The medical record is the answer. Medical documentation or medical record documentation is crucial for information sharing between doctors, nurses, and staff. It is pivotal for health care to give a standard of care to patients. We will be discussing more medical documentation and its importance in this blog.
What is Medical Documentation?
Medical documentation is the methodology that healthcare workers use to keep track of a patient’s healthcare status. It demonstrates to others that the healthcare professional is particularly aware of what he is doing to take care of his patients. The content of medical documentation includes records of the patient’s medical history, including vaccination dates, medications, diagnoses, surgeries, recommended treatments, x-ray results, ECG reports, scan reports, past therapy, lab test results, and allergies. It also helps to improve the quality of healthcare services provided to patients. Improper documentation in medical records may ensue dire consequences.
Why is Documentation Important in Healthcare?
Without sufficient documentation, it is hard to plan a treatment path. Clear and understandable documentation will be helpful for future physicians to continue timely progress and the best possible treatment without any hindrance. The importance of documentation lies in assisting the patients’ subsequent treatment.
If you ask which of the following is a purpose for medical documentation, we can’t specify one thing alone. Let us see them all in detail. To avoid litigation and complaints, patient documentation is a powerful weapon. It lowers the chances of treatment errors and increases the probability of a favorable outcome.
Unbiased medical documentation allows the treatment team to communicate with each other, as well as to approach the patient with care. The purpose of medical documentation is not only for the standard of care but also helps to identify any gaps in the treatment strategies and to improve the quality of care.
Healthcare professionals must record every detail about the patient. Let’s have a look at a case that reflects the importance of proper medical documentation. A patient visited the physician for chest pain. The doctor treated him with the standard of care. On his tenth visit, the doctor suggested the client meet a cardiologist. The patient refused his recommendation and stated some reasons for that.
In the medical record, the physician failed to document that the patient refused to meet the cardiologist. Twenty days after his last appointment with the doctor, the patient died due to heart valve disease. His wife filed a lawsuit against the physician. The physician, in this case, had to settle the amount in court. Now you would have understood the aftermaths of medical charting errors and the importance of proper medical documentation.
Medical Record Management
A patient record must be carefully saved, safeguarded, and maintained from the moment it is created. Medical professionals have the responsibility to protect and maintain medical records with security. To manage medical records successfully, an organization must define some procedures and policies to maintain data security. They should conduct record management programs in the organization to give awareness to the professionals.
Training should be provided to the employees periodically to avoid mismanaging records. The professionals must have the knowledge to handle it. A recent study says that more than 50 percent of careless employees are the reason for security issues. So the professionals working with the patient record should be trained well. Keeping indexing system covers will be helpful in handling the medical charts from creation to destruction.
Paper records should be kept in a secure room with limited access to increase data security. As a result of rapid technological development, more than 95 percent of hospitals use electronic medical records (EMR) for easy maintenance. According to the ONC survey in 2016, more than 96 percent of hospitals use electronic health records (EHR). It has the advantage over paper records. Medical records have a retention timeline. After the timeline, it should be destroyed. Paper records should be shredded and burned, and electronic medical records should be cleared using overwriting software.
Why Should You Keep an Accurate Medical Record?
The patients may not always visit the same physician every time for treatment. If the medical record is high quality and accurate, all the physicians can follow it and provide the proper medicine. To retain an accurate medical chart, it should contain details of the patient’s information, for example, date of admission, name of the patient, demographics, and date of birth. Then the advice and information given by professionals should be meticulously recorded. Medical history, recommendations, consent forms, undergone surgeries, lab reports, details of any drugs prescribed, and notes from mobile conversations should be mentioned.
An accurate medical record is crucial for safe and effective health care. It helps to communicate with other professionals to identify the patient’s status. The General Medical Council recommends that everything should be recorded in the medical record at the moment of the patient visit or as soon as possible subsequently. Following this recommendation helps the professionals to keep accurate medical records and provide the standard of care.
Keep in mind that the patient has the right to access their medical chart. The reliable medical chart protects you against the settlement at court when the clients request a medical record, narrative medical record, or medical record review for their personal injury claim or other purposes. Therefore the content of the medical documentation should be error-free.
Dr. Mark Schnitzer presented to the associates today about the power of questioning to tease past medical history information out of patients as well as the importance of thorough documentation in all healthcare careers pic.twitter.com/r2uI3796d0
— SCC CAPS Healthcare (@SCCCAPSHealth) October 13, 2020
Electronic Medical Records (EMR)
Electronic medical records (EMR) are the digital version of paper records. EMR includes patient health history or status. EMR is used to improve the standard of care and reduce medical errors. It contains the medical history of the clients, including vaccinations, drugs, diagnoses, surgeries, allergies, lab results, and recommended treatments.
Advantages of EMR
- EMR increases the efficiency and quality of medical documentation.
- Handwriting or transcription errors can be reduced.
- EMR is easy to read and organize compared to the paper medical record.
- Physicians can access patients’ data from anywhere with an internet connection. So it’s very flexible to use in any location.
- It reduces errors in medical documentation.
- EMR is more convenient to use
Disadvantages of EMR
- All information about the patient could be lost if a technical issue occurs and EMR software doesn’t have the backed-up data.
- Power outages or no internet connection affect patient care.
- The time needed to provide EMR training is more.
- High cost
Electronic Health Records (EHR)
EHR is a digital record of patient health history. It is used to store and share patient data. It helps to improve the accuracy of medical documentation. The patient can access their health record. EHR contains all the information, which includes electronic medical records and much more. It consists of the previous treatment, surgeries, and all the information about the patient.
All the professionals in health care can access the medical health records since it travels out of practice. It contains the medical history of the clients, including Allergies, immunizations, drugs, diagnosis, procedures, and recommended treatments. It also contains patients’ demographic information, insurance information, etc.
Advantages of EHR
- Provide accurate information about the patient
- Patient and professional’s interaction and communication will be improved
- It increases patient safety and decreases medical errors.
- Patients can access their healthcare information in the EHR system
- Less paperwork and fewer storage issues
Disadvantages of EHR
- It is significant to update all the details about the patient after every consultation. If you fail to do so, the physicians who refer you the next time don’t get conventional information.
- Security issues of the patient data are another disadvantage of the electronic health record.
- Computer failure or power shortage can make the information inaccessible.
- It takes more time to provide training to employees.
- Start-up costs are tremendous
Retention Time in Medical Records
Retention time defines how much period the physicians or hospitals should keep the medical records. Federal law mandates that the professionals must keep the medical records a minimum of 5 years to a maximum of 10 years from the last service of the patient. After the retention time, the hospital can destroy the records. The medical record retention period may differ state by state, and also it varies according to the patient’s age.
In Arizona, the retention period to maintain records for an adult is six years, and for minors, six years after the last treatment from the provider or until the patient reaches 21, which is longer. In Arizona, both the hospitals and professionals have the same retention period to maintain the medical records documentation.
In Connecticut, the physicians must keep it for seven years from the last date of discharge or three years after the death of the patient, and the hospitals must keep it for ten years from the clients’ discharge.
In Columbia, the doctors must keep an adult’s record for three years after the last meeting with the doctor, and for the minor patient, three years after the final visit or three years after the patient reaches 18. The hospital must keep ten years following the date of discharge.
Can we Request Medical Records?
According to the Health Insurance Portability and Accountability Act (HIPAA), patients have the authority to request medical records. If you are a guardian, parent, caregiver, or advocate and has acquired the patient’s written approval, you can request a medical chart on behalf of the patient. Under the law, third parties may also request medical records if they receive a signed authorization form from a patient, whether knowingly or innocently.
How to Request a Medical Record?
As a patient, you may need to get medical records for various reasons. When you move from one place to another, you can show it to your new doctor for your future care. Having your medical records on hand will assist you in spotting errors and saving your life. The requisition process is not easy if we don’t know the procedure to apply. Knowing the procedure may ease the process. The steps to be followed are to request a medical record.
Medical Record Release Form
The medical record release form contains the details, including information about the patient, date of services, hospital details, care providers, information to be released, the purpose of release, etc. An increasing number of medical facilities are making their authorization forms available online so that patients can fill out the form on time. However, patients aren’t allowed to see some kinds of records. For example, psychotherapy notes are protected from demands.
According to HIPAA, providers have no more than 30 days to respond. After applying, one should wait between 30 to 60 days. In some states, they can receive within 30 days; however, some state regulations allow for a shorter time. It varies by state.
Select the Required Part
The authorization form includes the selection of the required part. So, it is significant to mention the required details. The medical record contains more than 50 pages, so being selected is very important.
The physician can receive a reasonable amount for a copy of the medical chart. Service costs vary by state. In Arizona, professionals can get a reasonable fee for a copy. In Arkansas, the clients must pay $15 for the processing charge, $0.50 per page, copy fees for the first 25 pages, and copy fees for additional pages is $0.25/page. If patients request a narrative medical record or medical record review, they must pay some extra cost.
After receiving the medical record, if you find any error, you can request a correction. You should have them fixed right once so that your future care is not affected. Otherwise, it may lead to some medical errors leading even to death.
Medical Documentation and Medical Record Review
Medical records review includes acquiring and assessing a person’s medical records, which may include hospitalization records, medical history reports, lab findings, etc. Lawyers need the medical record to handle cases like personal injury or medical malpractice claims etc.
Attorneys require to acquire the details of a particular part from the medical record that is related to the subject case. Attorneys don’t get enough time to do medical reviews. So they submit patients’ medical reports to medical record review companies to review what they need for their claims.
Tips to Avoid Errors in medical Documentation
The following tips will be helpful in avoiding errors and confusion in medical documentation procedures.
- Avoid abbreviations and shorthands.
- Don’t forget to write the date and sign your notes
- Avoid unnecessary comments
- Medical documentation should be done daily basis
- Use a good pen if you want to note anything by hand.
Medical documentation and electronic health record `is vital for both health care and patient care, as we’ve seen throughout this blog. A quality medical chart is the best defense against any lawsuit. So it’s the healthcare obligation to keep the record safe. With advancements in technology, we have the facility of electronic medical records and electronic health records to increase the accuracy of medical documentation.
Even though they have some drawbacks, it is better than paper medical records in maintaining the efficiency of medical documentation. Avoiding medical documentation errors will save medical practitioners from possible medical malpractice lawsuits.