86% of healthcare mistakes are administrative, making accurate medical record keeping a life-or-death issue. Preventable medical errors are the third most common cause of death in the US, claiming 40,000 lives every year.
Medical records include electronic documents, voice recordings, lab results, and anything else that contains a patient's health information.
Every medical practice needs to keep track of medical records to make them easy to access and use. This allows them to provide the highest possible level of patient care, prevents clerical mistakes, and comes in handy if legal issues arise.
Read our guide to epic medical record keeping.
Medical Record Keeping
Healthcare providers need to fill out 20,000 forms every year. It's understandable if they have trouble managing this massive amount of paperwork.
While it may seem like an impossible task, quality medical record keeping is possible.
You simply need to develop the right process. This involves creating quality records, using the right systems, focusing on security, communicating, maintaining records, and more.
Creating Great Records
Accuracy is arguably the most critical component of medical record keeping. Every record needs to have the right information and be recorded at the exact date.
Medical records need to be detailed enough to contain all the necessary information. This could include clinical findings, treatment decisions, prescriptions, and consent for treatment and/or examination.
All records need to be legible and easy to understand. This applies whether they're electronic or handwritten.
Using the Right System
85.9% of office-based physicians use an electronic system for managing patient records. While they're becoming the norm, they differ in quality.
When looking for an electronic records system, there are several factors to keep in mind.
Choose one that's compatible with the computers and technology your office uses. This will ensure it's easy to install, use, and learn.
HIPPA or the Health Insurance Portability and Accountability Act also sets requirements that your electronic records system must meet. Ensure that it obeys the law before buying it to avoid nasty fines and penalties.
Choose a system that provides support if anything goes wrong. Systems failures put patient records at risk, and you should be able to call the company to remediate them as soon as possible.
Once you've chosen the right electronic system, you need to know how to use it to keep patient records accessible and secure.
Transferring from paper to electronic medical records can be a difficult process, but with the right steps, it's not impossible. Scan each piece into a secure database that's easy to access.
Your records should be easy to retrieve for both patients and employees. Patients should always be able to see their records if they ask for them, and employees should be able to quickly obtain the records they need to do their job.
Patients who see their records may notice inaccuracies or issues they want corrected, and they have the right to request you do so. When making changes to any medical records, be sure to do so carefully.
Make a note of the exact date that you change any records or make any retrospective entries. This will help you keep an accurate record of when the information was altered.
Security
When using electronic data, you must back it up often to protect against attacks.
17,000 patient records are breached every day. You need to set practices in place to ensure that information remains secure.
Use a secure system for any electronic records that includes encryption, passwords, and other forms of protection. Keep any handwritten records in a locked area that only authorized individuals can access.
You should have a security team in charge of protecting records and the systems that store them. You should also have a disaster recovery plan in place for how to recover data in case of a breach, power outage, or other issues.
Communication
25% of patients reported that their records didn't transfer from one healthcare provider to another in time for their appointment.
Clear communication is an integral part of proper medical record keeping. Use a system that allows every doctor your patients see to access their records. Make sure it's also secure to prevent unauthorized access.
Maintaining Records
Knowing how long to keep medical records is another important part of medical record keeping. The exact timeline depends on the situation and area.
The answer to the question of ‘how long do hospitals keep medical records' depends on the area, as the laws differ from state to state. They typically require maintaining a patient's records for 10 years after their death.
Answering a question ‘like how long should I keep a medical record' also depends on the type of record it is. Pediatric records have different retention requirements in each state.
A child's medical records must be maintained for 10 years past the age of majority plus the statute of limitations. In some areas, this could mean retaining the records until patients turn 18.
HIPAA regulations require you to maintain certain documents for 6 years from when it was created or last in effect. These include business contracts, health information disclosures, responses to requests to amend records, and more.
To destroy a health record, you must use a confidential destruction process. Removing irrelevant records is an important part of medical record keeping. It improves security by keeping data safe and cleans up databases.
Other Tips
Be willing to modify your medical record keeping policies at any time if the need arises. New technologies develop every day that may help you stay on top of your paperwork more efficiently than you could before.
If you do decide to change your policies, be sure to communicate the new standards to employees. You should also provide them with the resources and training they need for proper medical record keeping.
You may also require professional help to fill any gaps in your policies. Medical chronologies provide a detailed summary or timeline of all your medical records, making them one of the most helpful medical record keeping services.
Where Can I Learn More?
Medical record-keeping is one of the most crucial and most difficult parts of running a successful healthcare business. It's difficult to manage a massive amount of patient information and to know how long to keep it for.
When maintaining medical records, start by creating accurate, legible records that everyone can access. Put them in a great electronic system, keep them secure, and maintain them.
About the Author: Steffy Alen is a copywriter and content strategist. She helps businesses stop playing around with content marketing and start seeing the tangible ROI. She loves writing as much as she loves the cake.
