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The Importance of Accurate Medical Records

SyberScribe AUTHOR: SyberScribe, November 10th, 2019

If you run a medical practice and see patients on a regular basis, it’s important to keep accurate medical records. This way, you can ensure quality patient care and meet legal and ethical obligations. Here’s a closer look at some of the reasons why accurate records should be kept at all times, as well as some helpful tips on the best ways to achieve this.

Why you should keep accurate medical records

1. Good patient care

In the past, doctors kept medical notes on their patients largely to remind them of their condition the next time the patient visited them. But with clinics now becoming the prevalent form of healthcare, a patient may not see the same doctor on every visit; having accurate records is vital to allow any practitioner to take over the patient’s treatment simply by referring to their records.

The absolute minimum standard for accurate medical record keeping requires that records be legible (preferably not hand-written and ideally digital) and contain:

  • Patient demographics, such as name, date of birth, and contact details.
  • Progress notes that document a patient’s clinical status or achievements during hospitalisation or outpatient care.
  • Specialists’ letters and other correspondence.
  • Advice or information given and consent discussions/forms.
  • Video or audio recordings.
  • The patient’s medical history, including allergies, health conditions, and medical or surgical procedures.
  • The practitioner’s examination findings, including test results, X-rays, scans, and photographs.
  • The provisional diagnosis reached.
  • Any other diagnoses that were considered.
  • The management plan, including recommended treatment, tests ordered and medications prescribed.

2. Effective communication

Accurate and timely medical records are also essential for effective communication between medical professionals and their patients. The next time a practitioner sees a patient for their continued treatment, they simply have to look at the patient’s records to remind them why they’re visiting, avoiding unnecessary questions or giving irrelevant advice/information.

On the other hand, when a patient sees a different medical practitioner, they won’t have to waste time repeating information they said to the previous practitioner, whereas the practitioner can ask the right questions, give the correct answers, and know the next step to take regarding the patient’s treatment.

3. Better practice operations

Accurate recordkeeping improves the day-to-day operations of a medical practice. It ensures that information is handled, categorised and stored correctly, reducing the chance of mistakes being made which could lead to breaches of privacy. It also allows staff to do their work more effectively, as they can find patient information quickly and easily, ask patients the right questions, and answer patient questions correctly. In addition, accurate medical records during a medical crisis or pandemic help eliminate the risk of mistakes, allowing all staff to focus on providing service at time where effeciency and good communication is critical.

4. Assist with audits and Medicare payments

Having accurate medical records can assist with audits and Medicare payments. For example, if a medical practitioner is asked to participate in an Australian Taxation Office (ATO) audit or a health provider compliance audit, accurate records can help them pass the audit. Additionally, medical records must be accurate to ensure that they receive correct Medicare payments and can justify payments if audited.

5. Personal protection

Keeping accurate medical records can also protect a medical professional from any disputes that might arise about treatment, alleged compliance breaches, and even lawsuits that might be brought against them.

In a medically-related lawsuit, hearing or inquest, or when patient care provided by the practitioner is in question, it’s always the patient’s medical records that are examined first. Ensuring they’re accurate is a medical professional’s best defence against any allegations that might be made. For this reason, the records should always be entered in a timely manner and never altered or back-dated in any way.

Privacy laws also require that medical records are stored securely and made available to the patient upon request, and keeping timely and accurate records will help to protect a practitioner from any potential breaches of these laws.

Recordkeeping tips

The following tips can help to ensure that your medical records are accurate:

Include relevant and up-to-date patient information

This includes all matters that are relevant to the patient’s care, such as history, findings, diagnoses, treatments, care rendered and advice given. A patient’s medical record must also be regularly updated in chronological order to show continuous care and response to treatment. According to the Health Insurance (Professional Services Review Scheme) Regulations 2019, the record should contain the patient’s contact details, separate entries for each visit including the date and service rendered, and adequate clinical information on the services rendered.

As a rule of thumb, it’s better to err on the side of caution and include too much information in your medical records rather than too little, because as the old saying goes, ‘If it’s not in the record, then it didn’t happen’.

Write entries clearly and objectively

Make sure all entries are clear and readable, so that other practitioners can safely treat the patient. Don’t use abbreviations, unless they’re standard medical abbreviations. Be specific at all times and use objective language. You shouldn’t make any derogatory references to the patient that might be misconstrued at a later date.

If an error is made in a written entry, draw a line through it and write the time, date, and your initials in the margin. Never erase it or use white-out on it. Then draw diagonal lines through any blank spaces left after a written entry. Finally, initial or sign all entries, add the date and time and make sure the patient’s name is on every page.

Keep medical records secure

All staff working in the medical practice should comply with theHealth Records and Information Privacy Act 2002, back up medical records to a remote data storage facility or on backup discs that are stored offsite, and set up passwords on computers. This ensures that the confidentiality and privacy of patient information is maintained.

Keeping medical records safe and private also ensures that no medical professional mishandles the information and that no unauthorised changes are made, maintaining the accuracy of the records. Access to medical records should also comply with privacy legislation.

Train staff and review the recordkeeping system

Regularly train your staff in recordkeeping, such as recording on paper or using records management software to capture patient clinical information and determining what information to record. You can also improve your record accuracy by using voice to text software likeDragon Naturally Speaking, tablets and hybrid laptops for making notes, orvoice recording devices to capture notes.

Don’t forget to periodically review your recordkeeping system to ensure that the design facilitates documentation of the relevant clinical elements and that the processes for information capture are working effectively. Also, audit the performance of the system to determine if it needs improvement.

Use a medical transcription service

This involves dictating your notes into a voice recorder or mobile device and then emailing or voice streaming them to an outside transcription service, often based in the cloud, for accurate transcription, storage, and retrieval.

At SyberScribe, we employ medical transcribers who have experience in the medical field, accurate typing and transcription capabilities, and a good 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,contact us today and see how we can help you take the hassle out of recordkeeping.