Maintaining Accurate Health Records

One of the essential components of running a private medical practice is maintaining accurate health records. Maintaining accurate health records will enable your practice to meet legal and ethical obligations, but also to be well-informed on patient information and offer the best possible care. This week we will explore some of the reasons why maintaining accurate health records is essential, as well as some tips on how to achieve this.

Patient Care

For doctors in the past, keeping accurate health records enabled them to be up-to-date and aware of their patient’s health information. Keeping accurate healthcare records is an important way to keep track, but also to best prepare other doctors in case a patient is seen by another doctor within the practice. This is an important action to take in representing your practice, as it enables a uniformed approach in treating patients by providing the information that will allow others doctors to take over the patient’s treatment.

Successful Communication

Not only are accurate medical records essential between doctors when they are treating a patient, they are vital for patients, too. This prevents the patient from having to explain their medical concerns to each practitioner, as the records detail all of this information. This saves time and can feel more valuable to a patient, as time doesn’t need to be wasted by going over anything, and the practitioner can ask the appropriate questions.

Improve Practice Operations

Accurate health records can improve the running and day-to-day operations of a practice. In a practice, it is vital that information is categorised and stored correctly so that it can be handled appropriately. This can also prevent against mistakes and breaches of privacy.

The pandemic has exposed how important good communication and efficiency is. Organised and sufficient medical records can make the running of a practice more streamlined and can save time in practice operations. This will undoubtedly come across when the practice communicates with their patients.

Protection

Maintaining accurate medical records protects against any complaints or disputes that may arise about treatments. If a patient’s medical records are poorly maintained or inaccurate, mistakes may be made which can result in complaints. More still, if unfounded complaints are made, accurate health records are a medical professionals’ best defense.

If medical records are stored appropriately, this will also keep to the privacy laws which protect patient information.

5 Tips To Improve Health Records

1. Ensure that records are up-to-date – A patient’s medical information should be in chronological order and consistently maintained.

2. Include all relevant information – Make sure to include all relevant information so that the health records are informative enough for another doctor to take over treating the patient if necessary.

3. Make sure entries are clear – Entries must be clear and readable. If possible, use digital records instead of hand-writing them. Use objective language and refrain from using abbreviations.

4. Make sure medical records are secure – Ensuring the security of medical records will protect your patients and your practice and prevent against security breaches and mistakes.

5. Consider using a medical transcription service such – Recording your notes via our dictation app can help to produce accurate healthcare records.

We have specialist knowledge and expertise in medical transcription, so why not contact us today to see how we can help.