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How to manage records in software?
- December 12, 2018
- Posted by: admin
BENEFITS OF MEDICAL RECORDS MANAGEMENT
As the requirements for medical records change, it is important for medical practices, hospitals, skilled nursing facilities, and long-term care facilities to have a medical records management system in place that includes automating, capturing, storing, and disseminating records. The system improves record location and tracking, even for records people don’t frequently use. It can also preserve historical and vital information about a medical facility in case of a disaster or legal requirement.
A records management system can also make it easy to transfer or release information between offices — both patients and physicians can access the information in a timely manner without duplicating efforts. Arguably, this type of visibility can increase patient safety, reduce mistakes, and increase confidence in a treatment plan. From a productivity standpoint, medical records management might address litigation risks, lower operating costs (due to reduced physical storage needs), and boost employee productivity, mobility, and efficiency.
RISKS OF UNMANAGED MEDICAL RECORDS
Not having easy access to potentially life-saving or life-changing health information is a significant risk that unmanaged medical records present. A lack of organization with regard to record keeping can also pose a legal threat. Additionally, when staff are constantly struggling to find things, patients might view the lack of structure and policy as a signal that a practice is behind the times.
Inefficiency can also lead to a loss of productivity, duplication of efforts, or an inability to complete necessary tasks. Billing errors could arise as a result of poor records that ultimately cost the practice money. Paper records also require a physical storage area and can sometimes result in practices needing to purchase additional office space, which can be expensive.
When individuals create their own non-standardized systems, they are exposing an organization to more potential issues. For example, it could lead to insufficient backup plans and increased costs to convert records from formats that adhered to technology that eventually became obsolete. Simply having backups of data in multiple places is pointless if it is not accessible or usable.
Unfortunately, many medical facilities do not see medical records management as a critical or necessary function. As a result, they do not provide training or structure to create an efficient and compliant policy.
WHAT IS INVOLVED IN MEDICAL RECORDS MANAGEMENT?
Medical records management involves many kinds of records, including patient charts, x-rays, images, scans, and even emails. Additionally, it involves making sure all of these items are accessible, safe, and secure.
Unless a practice is brand new, there are probably still some paper charts in the office. Deciding what to do with those charts is vital to the success of any medical records management system. Simply scanning them into an electronic format will not necessarily make them easily accessible for people who need them. A company that specializes in this kind of records transfer (from old to new technology) can make sure they are created properly and adhere to best practices, regulations, and retention schedules.
Clinics must consider the following questions:
- Which historical patient information should be available for patient visits during and after the transition?
- What are the best methods of converting this information to the EHR?
- What is the best way to ensure that the converted data and information is of sufficient quality?
- How long should the paper record be available after the conversion?
- How long do paper records need to be kept after the transition to the EHR?
- What is the role of printing and should it be allowed during the transition?
These answers may be different for different types of practices. For example, those specializing in cardiology might need to keep previous test and diagnosis information more readily available than other practices, since they refer to them often to look for anomalies or trends. Results of a one-time test or procedure might not need as much access. Organizations may need to also decide if someone will manually input important data like allergies, procedure history, current medications, etc., into the new or updated system.
Since some medical records link to practice management systems, the revenue cycle and billing could all be part of the same system, making things easier for both patient and practice.