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Best Practice Tips and Advice for Better Medical Record Keeping

AUTHOR: SyberScribe, August 16th, 2017

Medical record keeping is under increasing scrutiny in Australia, with practitioners under pressure to meet higher standards for their patients. Matters aren’t helped by increasing pressure on medical facilities, with less government support and funding.

While maintaining accurate records can seem like a chore, with a bit of planning, practice and the right technology, you can meet legal and ethical obligations without too much pain. Here are some steps you can take to implement better record keeping habits at your practice.

Know your obligations

In Australia, medical practitioners have a statutory obligation to maintain accurate records for their patients as covered by the Health Insurance (Professional Services Review) Regulations 1999.

To meet these obligations, the records should:

  • clearly state the name of the patient
  • contain separate entries for each visit including the date and service rendered
  • contain adequate clinical information on the rendered services
  • be legible and comprehensible so that other practitioners can safely treat the patient.

At a minimum, if you can meet these four requirements with your records, you’re well on your way to meeting your legal obligations.

What happens if you don’t keep adequate medical records

Failure to keep adequate medical records opens up a whole range of issues for medical practitioners and patients, including:

  • lack of adequate care
  • lawsuits
  • hearings and inquests

Beyond legal obligations, there is an ethical duty of care for practitioners to provide both adequate treatment and record keeping. For clinicians looking to update their record keeping practices, it can sometimes help to think of record keeping as an intrinsic part of patient treatment, rather than an extra component. By viewing record keeping as a necessary step in treatment, you’ll be more compelled to provide accurate documentation for your patients.

Plan and plan again

Tradesmen have a saying, “measure twice, cut once”. The same is true of planning; it’s better to spend a little extra time on your scope and strategy before diving into the process. When crafting your plan for a top quality medical record keeping process, you should:

  • get feedback from all stakeholders
  • provide clear expectations
  • devise a plan that can be reasonably implemented and meets all the requirements of your practice

Regular training

Most organisations suffer from a similar prognosis when it comes to training. They go big upfront, and then forget to revisit. This presents a number of problems:

  • new staff rely on existing staff for ad-hoc training
  • staff on leave miss out
  • bad habits creep in
  • proper processes are forgotten or discarded

While it’s important to train your staff on new record keeping practices prior to deployment, it’s just as vital to revisit these practices on a regular basis. Regular training will allow you to update your processes, collaborate on feedback and solutions, and stay in touch with regular concerns of your staff.

Build and maintain the habit

Strong habits and routines are what build impeccable record keeping processes. The actual routine itself doesn’t matter as much as keeping to it (provided the routine meets your objective). Some like to prepare their notes during or immediately after a consultation, others at the end of the day.

Whichever way you choose to build habits at your practice, make an effort to maintain them, build from a strong foundation and soon good record keeping will become second nature.

Maintain clinical professionalism

Personal recordkeeping needs to be clinical and maintain a professional standard at all time. Subjective comments should be left out, as they might be taken as offensive and could be used against you and your practice in legal actions.

This goes for staff at all levels in your business. A good way to vet new staff is to peer review their records for professional standards and conduct regular workshops on best practice note taking and record keeping.

Keep it legible

As per statutory requirements, medical records need to be legible. Illegible notes are simply bad record keeping, they also make it difficult for other clinicians to treat the patient. Typed records are better than handwritten and should be encouraged in your organisation. While handwritten notes are legal, there’s much less risk with a typed record.

Update technology

The right technology can improve your record accuracy and make processes faster and easier. And it’s not just records management software you can invest in to improve records accuracy. Consider:

Hire a medical transcriber

For many clinicians, typing up handwritten or recorded notes is a chore they simply don’t have time to complete. By hiring a medical transcriber, you’re getting professional help with an essential part of your practice.

Professional medical transcribers usually have experience in the medical field, accurate typing and transcription capabilities, and a broad understanding of the obligations and practices in Australia. If you’re looking for a pain free way to maintain more accurate records for your patients, now could be the perfect time to try out a medical transcription service. Talk to SyberScribe today and see how we can help you take the hassle of out of record keeping.