Medical records management is organizing and handling patients’ health information in a way convenient for medical professionals to access and carry out healthcare workflows. Patient records are created when people walk into a clinic or healthcare center for the first time. Health records management involves rules, regulations, procedures, and protocols to manage health records throughout their existence. This involves updating, modifying, communicating with other providers, and ensuring privacy and integrity. Managing health records is important since the data it contains leads to treatment decisions by doctors.
A medical record management system enables physicians to access patients' medical information. This contains details like treatment history, immunizations, allergies, previous medications, pre-existing conditions, etc. This is vital for doctors who need to prescribe tests, scans, or medications for patients. A person’s health history can impact how he or she responds to certain treatments, so health records are important for making informed decisions.
OSP can build a patient record management system to act as a centralized location for patients' medical information. With this, doctors can access, update, modify, and share it with other providers to collaborate on care or as part of referrals. In addition to helping with care, this also lowers the administrative burden and reduces operating overhead. These benefits invariably free up time and resources for doctors to devote elsewhere.
The health information stored on medical records is vital for patients as it influences providers' treatment decisions. OSP can develop medical records management software with multiple security features that prevent unauthorized access or unethical use of patients’ health information. This ensures that people’s protected health information is safe and reliable for use in case of emergencies or during ongoing treatments. Our platform for medical records management will streamline workflows without compromising security.
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We reached out to OSP to provide an estimate on a technology solution we were interested in developing. From the initial conversation, the team was professional, courteous, and thorough. We were able to make a quick decision to move forward with OSP because we were confident that our requirements were accurately captured and the development deliverables and associated costs were clear.
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Medical records management is organizing patients’ health information in a way that makes it easy for doctors and other medical professionals to access it. Fast and simple access to patient’s medical data is important for clinical workflows and billing operations. Every person who has ever had to visit a doctor for the first would have his or her health record created.
There are certainly vital aspects of medical records management –
Client’s Words: The patient’s description of his or her symptoms must be recorded exactly as they say. The entire clinical visit needs to be documented precisely to facilitate accurate diagnosis.
Clarity: Using the correct clinical terminology to describe patients’ clinical visits, symptoms, and conditions is essential.
Accuracy: The documentation of the patient’s visit must be concise and to the point, while also being completely accurate. This is an essential factor for efficiency in managing medical records.
Chronology: The order of all the entries in the medical records must be proper to help providers know about patients’ health history. For certain diseases and conditions, the chronology of medication and treatments might be crucial for further clinical decision-making.
Privacy: The data in the patient’s medical records are confidential and can only be accessed by licensed medical professionals authorized for it. These are usually the providers involved in the direct care of the patient. Sharing of this data requires prior consent.
The best way to organize patients’ health data is according to category and chronology. The chronology must include the dates of all the tests, scans, procedures, immunizations, admissions, and prescriptions from the earliest to the most recent. The categorization of the records should be done in a way that is possible for physicians to access the relevant parts of the overall patient data. So, factors like surgeries, tests, visits to the emergency room, as well as prior and existing conditions like asthma, diabetes, heart disease, and so forth, must all be categorized accordingly.
EHR (electronic health records) software is a must, especially for large hospitals and medium-sized ambulatory care centers. It enables fast and secure access to clinical records while ensuring patient data privacy and integrity. Physicians can view health information with a few clicks using an EHR platform.
Patient Identification: This is central to all medical records. All the patients have a unique identification to locate and view their records whenever necessary. It identifies which record belongs to whom.
Medical History: This is one of the most important parts of the overall medical record. It describes the patient’s health history, which includes allergies, immunizations, previous diseases and conditions, treatments, and so forth. This information is important for doctors to make treatment decisions for all patients.
Family History: This highlights the history of diseases in the patients’ families. People are more vulnerable to certain diseases if either or both of their parents or grandparents have them. This information helps doctors decide on treatments.
Treatment History: This part of the medical records contains data about all the previous treatments patients have had. It includes the medications prescribed, procedures carried out, diagnoses, etc. This is important as patients with a certain clinical history cannot be given certain treatments for newer conditions.
Patient Instructions: This is highly important for providers to avoid legal liability. Patients might leave prior instructions for physicians to carry out certain processes, or avoid them, in case they are not physically fit to do so before, during, or after certain procedures. A DNR instruction (Do Not Resuscitate) is one of the best examples. Failure to comply with this will lead to legal action.
1. Data Collection
One of the first and most important jobs of medical records management. The data could include demographic information, medical history, family history, previous medications, diagnoses, immunizations, etc. It helps providers get a complete picture of the patient’s health situation.
Electronic prescriptions are digital platforms where providers can write their prescriptions and which patients can send directly to pharmacies. This helps avoid medication errors due to illegible handwriting and lets doctors view which drugs are covered in a patient’s plan.
3. Online Appointment Scheduling
Being able to book appointments online is highly convenient for providers as well as patients. Providers won’t have to maintain a separate staff to manage appointments, and patients can schedule and re-schedule them at per convenience. Additionally, online appointment scheduling is also favorable for telehealth.
4. Clinical Support
Medical records with a module for clinical support will automatically send notifications and reminders about tests and scans. This is especially helpful for patients suffering from chronic diseases
5. Billing Features
Medical records platforms with billing functions accelerate all the processes involved in medical billing by speeding up the process of gathering data on clinical visits.
6. Maintaining Usability
Keeping the records updated with the latest test results, diagnoses, treatments, and medications is important. An updated record will help future physicians treat patients properly.
Some of the expected trends in medical records management include the following –
1. Cloud-Based Records
EHR software is mostly installed on-premises at hospitals and clinics. But providers across the country are shifting over to the cloud as it is easier, more convenient, and prevents the need for investing in dedicated hardware with IT infrastructure.
Healthcare automation technologies have been increasingly adopted throughout the industry. Automation replaces humans’ need for repetitive manual activities, so it can boost the speed and efficiency of the records management process while minimizing errors.
Analytics is one of the most promising trends in medical records management. Using analytics with medical records will reveal vital insights that will boost clinical care and help manage the records better.
IoT has shown great promise in healthcare monitoring by sharing real-time health data of patients with providers. How that data can be used in the diagnosis and the same updated medical records remains to be seen.
5. Artificial Intelligence
There is no limit to what artificial intelligence can do in healthcare. The applications of AI in healthcare could include everything from drug discovery, public health, and disease management to billing and coding and everything in between.
Record management in healthcare is organizing medical records so that it is fast and simple for providers to access them when needed. When physicians can access the information they need, they can make informed decisions about treatments faster and with greater reliability. In other words, effective medical record management streamlines healthcare workflows.
Medical records management is a set of rules, regulations, and protocols for the governance, administration, and handling of medical records at healthcare organizations. On the other hand, EHR software is an electronic version of patients’ medical histories. It is the digital form of a person’s medical chart that contains all that person’s health information.
1. Creation: This is the first phase of medical records management. A patient’s record is created when he or she first walks into a clinic or hospital.
2. Maintenance: A person’s medical record must be maintained and updated after every clinical visit, diagnosis, prescription, test, admission, and procedure. It needs to be securely stored and its integrity preserved. The completeness or lack thereof of a health record can impact treatment decisions.
3. Usage: Providers access medical records when seeing patients know their health history, and treat them accordingly.
4. Disposition: Disposition can mean multiple things. For instance, all paper-based medical records are destroyed once digital records are available. In another instance, a person’s medical records might be destroyed after he or she is no more or if their integrity is compromised and it is rendered unusable. However, there are protocols and procedures in place to carry out disposition.
Medical records of a person reveal their health situation. This means that doctors can know their patients’ allergies, immunizations, medication history, previous procedures, etc. This information is invaluable in medical care, as a person with a certain condition or history of a condition will respond differently to certain treatments than people without any history of that condition.
In other words, access to medical history is vital for quality treatment and avoidance of medication errors. For example, a person with diabetes would suffer different outcomes from an ER procedure than someone without diabetes. Medical records ensure that doctors can make informed clinical decisions.