You should be aware of several vital things when it comes to effectively managing your medical records. Some critical factors include establishing effective communication with your EHR vendor, documenting measurable, repeatable, and objective facts, and protecting your practice from fraudulent claims and compliance issues.
Documenting Measurable, Repeatable, and Objective Facts
The medical industry is a complex juggernaut of information and communication technologies. Its essential pillars include health data, patient and professional communications, and patient safety. A robust recordkeeping program can be an influential hub for coordinating and communicating these critical activities. While the electronic medical records management Cary NC may have taken a back seat to mobile health applications, the old-fashioned paper-based medical form is still in the fold. Keeping track of patients, their medical history, and their medical conditions and treatments is a challenging task. That said, there are several best practices to help ensure the smoothest transitions.
In particular, an excellent record-keeping program is vital to a physician’s success. For example, it helps to document key observations and outcomes from the patient’s perspective, such as the patient’s medical history, medication list, and patient roommate and visitor interactions. By documenting these data types, a physician can perform better health management decisions and improve patient outcomes. Likewise, it is also essential to keep track of the patient’s vital signs.
Establishing Effective Communication With the EHR Vendor
One of the most critical aspects of building an electronic health record system is establishing effective communication with the EHR vendor. This is not a one-time task. Instead, it is a continuous process.
In recent years, there has been a growing interest in EHRs. They are a powerful tool that enhances productivity and improves patient care. Aside from their benefits, EHRs also ensure the confidentiality and security of patient data.
Implementing an EHR in a hospital can be a complicated process. It involves a lot of work and time. And the costs can be huge. Buying hardware and building an in-house team is expensive.
When selecting an EHR for your hospital, it is essential to choose the best. Many companies offer excellent services and products. But it is necessary to understand the advantages and disadvantages of each.
Continuity in Clinical Notes
Continuity in clinical notes is integral to a good healthcare record. However, clinical record-keeping can be a challenge, especially in emergencies. There needs to be more research available to measure the degree to which continuity can lead to better outcomes.
Several factors are associated with continuity in care. These include the distribution of roles, the availability of resources, and the overall health system itself. Using instruments to measure continuity can provide valuable insights into the most effective steps to improve care.
The literature suggests that continuity can be defined as transferring relevant information to different care providers. Good clinical notes can be an effective way to facilitate this process.
A practical clinical note contains the appropriate data regarding a patient’s medical history, medications, and lab results. It also provides the opportunity for collaboration between practitioners.
Source-oriented vs. Problem-oriented Records
There are two types of medical records: source- and problem-oriented. The difference between these two systems mainly centers on how data is collected and organized.
In the source-oriented model, doctors record patient encounters in a narrative format. This allows them to provide detailed information about the patient’s illness. However, this system can become time-consuming, especially when the patient has a complex case.
On the other hand, problem-oriented medical records allow clinicians to gather all relevant information about a patient’s medical problems in one place. Its primary purpose is to improve clinical decision-making. By focusing on a patient’s issues, these records can reduce unnecessary procedures and prevent medical errors.
These records also allow the patient to track their progress over time. They can also help providers and patients collaborate more effectively. As a result, these records can lead to better treatment, faster recovery, and shorter hospital stays.
Protecting Your Practice Against Fraudulent Claims and Compliance Issues
One of the best ways to ensure that you are not caught off guard by fraud is to have a compliance program. These programs help you spot erroneous claims and prevent them from entering your billing system. In case of a complaint, a compliance program can also demonstrate your best efforts to comply with legal requirements.
However, the agency acknowledges that solo practices will likely need more resources to implement the compliance guidelines.
A good compliance program consists of a few components. It should include a formal code of conduct that outlines employees’ duties, written policies stating the responsibilities, and a clear and concise method for monitoring and reporting compliance failures.