Importance of patient treatment documentation and record keeping
Ensuring completeness and accuracy of a patient medical history is essential and critical to providing safe and effective healthcare. Access to the historical medical records of a patient can be the critical differentiator. Medical professionals would want all past facts about a patient medical history to be available to them before taking clinical decisions. While some may argue that it does not matter if records are maintained in paper or in electronic form – retrieval and search is obviously much easier when records are maintained in electronic form. Besides, the risk of illegible handwriting is also eliminated when records are electronically available.
Health records comprise of documentation made during or after patient examination. Medical records could comprise of discharge summaries, referral letters, examination notes, lab reports, examination reports, videos, photographs, medical assessments and injury documentation, amongst others. It is important that medical practitioners pay adequate attention to what is being documented.
Notes need to be specific and free of inaccuracies to prevent inaccurate diagnoses and prescription of inaccurate treatments. It is recommended that notes should not be altered or changed; instead amendments and changes can be documented separately after signing and appending dates, as a best practice. Comprehensive documentation can facilitate quick decision making with a greater probability of arriving at the root cause of the medical problem.
Documentation should be free of offensive remarks, focus should be on objective statement of facts in its entirety. Accurate and comprehensive documentation of information greatly helps with continuity of treatment and care, more so in cases where a team of medical professionals are involved.
Medico-legal risks can also be minimized. It is also easier to track patient non-compliance. Even as the focus is on documentation, adequate care should be taken to maintain patient confidentiality and data protection. Your records need to be protected from unauthorized access and use.
Genamet is a user friendly and intuitive healthcare application that maintains patient records electronically (E.H.R). Genamet helps in appointment booking and scheduling, practice management and building a powerful web brand identity and presence for doctors, practices and clinics.