Good clinical records are critical for providing quality healthcare, maintaining continuity of care, and sharing information among healthcare providers. Electronic medical records, once created, should be updated so that any member of the care team can reconstruct a consultation or patient contact of the patient health records. Today, clinicians rely on medical transcription services to keep a permanent record of a patient's medical history and other information.
The Importance of Keeping Good Clinical Records:
Medical records are an essential component in providing patient care. Medical records include unstructured data in EHR free-form text fields, discharge summaries, progress notes, physician clinical notes, lab reports, photographs, faxed records and printouts, medical images, data on patients' socioeconomic status, and verbal correspondence between health professionals, addition to structured data with the variable name and a value (such as height, weight, and blood pressure, etc.) and stages of a disease diagnosis.
According to research, good clinical records will include the following items:
- History - pertinent to the disease, including all direct responses
- Examination of the patient
- All systems are checked.
- Important discoveries (such as disease diagnosis and stages) with blood pressure, peak flow, and other values
- Diagnosis differentiation
- Details on any investigations that have been ordered
- Specifics about the referral(s) made
- Patient instructions and information, including risks and advantages of suggested therapies
- Given consent for suggested investigations, treatments, or procedures
- Treatment consists of the primary drug doses, the total amount recommended, and any other therapy that has been organized.
- Follow-up entails making plans for more testing, appointments, and referrals.
- Progress - the patient's present status, any side effects or complications, any more consultations, and so on.
Clinical records must be properly dated and contain all of the information required by the healthcare team to make educated decisions regarding the patient's care. Poor quality documentation or insufficient medical records may have negative effects on both the practitioner and the patient, including:
- Incorrectly inform healthcare providers and patients
- Cause incorrect medical decisions
- Boost medical-legal issues
- This results in unneeded repeat testing or other investigations.
- Prolonged hospitalization
- Patient care must be compromised
- This can result in negative outcomes such as drug side effects, damage, psychological distress or trauma, or death.
- Revenue/reimbursement lost
Dos and Don'ts of Keeping Good Clinical Records:
Clinical records are the formal chronological documentation of the patient's health care and medical treatment. The health record must be clear, accurate, legible, and written professionally, as well as contain the aforementioned components. Here are some clinical documentation dos and don'ts:
Dos:
Maintain timed submissions: All entries must be legible, complete, timed, and signed. Making entries as soon as feasible after the incident, before the relevant staff person goes off duty, is best practice. If there are any delays, these should be documented, including the time of the event and the reasons for the delay.
Document any noncompliance: Physicians should document a patient's failure to take medication, get recommended tests, keep an appointment with a specialist, or other actions that a patient fails to comply with that cause or increases the risk of injury or delays the resolution of a medical condition.
Document conversations and informed consent: Physicians should meticulously record every patient's phone calls, including any actions performed in response to the contact. Document meetings with other members of the patient's healthcare team, as well as conversations about informed consent with patients and their families, are also required.
Don’ts:
Abbreviations should be avoided since they can cause confusion in patient care. MS, for example, can refer to morphine sulphate or magnesium sulphate. By spelling out the word, you can avoid ambiguity. In the medical record, however, it is permitted to use commonly recognized acronyms and abbreviations, such as HIV, GA, BMI, a.m., p.m., and so on.
Don't use potentially insulting comments: Patients have the right to examine their medical records, and an insensitive, personal, or disrespectful remark can harm your relationship with your patient as well as your credibility, especially if the record is utilized in court. Make objective observations. For example, rather than referring to a patient as misusing drugs, report on the patient's "drug-seeking behavior."
Avoid using deletion or corrections indiscriminately: After the final signature, never modify the clinical information/documentation. Follow proper error correction processes if a mistake is made in a medical record entry. All deletions or changes should be traceable to a specific individual, including the person's name, time, and date.
Good clinical records are essential for providing quality care, evaluating the quality of healthcare services, and pursuing malpractice claims. Maintaining security requires the safe storage of quality documentation.
Partnering with a HIPAA-compliant iTranscript360 medical transcription service firm, for example, helps assure data privacy and security in order to meet HIPAA requirements. Medical transcription outsourcing makes it easier to maintain clarity, accuracy, and timeliness in medical records.