Medical Record Keeping: from A to Z

In modern culture, the activity of any medical institution is classified as providing services to the public. Consequently, the patient, or consumer, can express his dissatisfaction directly to the attending physician. And sometimes the only proof of the doctor's correctness can be precise medical records.

The same is true in a reverse situation, when a healthcare professional wants to prove his right. When he is accused of mistreatment, for example.

In any case, records management is an integral part of the treatment process. Clinicians must keep them properly.

Let’s consider the main tricks and tips of records keeping to make your workflow easy to bear.

The Concept of Patient Records

This concept is much wider than people probably think.

Medical records is an established form of documents that are designed to register the results of preventive, diagnostic, therapeutic, rehabilitation and other medical measures.

Health records include many documents, such as the outpatient/inpatient medical records, the history of childbirth, the history of the development of the newborn and any other medical history.

The proper maintenance of documents by a care provider is a mandatory requirement for the implementation of medical activities. It does not matter under what organizational and legal form the clinic operates. It is important to follow the rules for keeping medical records, since this parameter of work is important for quality control and safety.

According to the General Medical Council (GMC), one of the indicators of the quality of medical services is a good record keeping. It should be noted that health documentation has the status of written and (or) material evidence in the judicial process. In the case of non-compliance with the requirements for maintaining clinical records (even if no harm is detected to the life and/or health of the patient), as a result, the clinic risks losing the lawsuit - for instance, in cases of violation of the rights of the patient as a consumer of medical services.

The subject of our discussion today is any document a doctor creates based on an examination and treatment of a patient. You can see an example of some of these types of records in the table below.

When creating a record in any of the above formats, whether that’s physically or remotely, it’s essential that you follow good practice in record keeping. This will ensure the best patient care and provide evidence in case of a claim.

The Basic Requirements for a Good Patient Record

The given legal requirements and recommendations are stated in such regulations as:

• General Data Protection Regulations
• NHS Records Management: Code of Practice for Health and Social Care
• Data Protection Act 2018

These regulatory documents give patients the right to check their own medical history when needed, meaning that they must be kept and stored properly (even after a person’s death).

The intriguing thing is that the regulations contain recommendations to switch from paper records to electronic records. This explains the popularity and growing use of electronic health records software.

Medical information must:

#1. Be filled in during the appointment

All health information should be kept in chronological order. They should contain information about the change in the patient's condition against the background of the ongoing treatment. This allows you to make a correct picture of the development of a particular pathological condition.

#2. Have a note about the date and time when the patient was examined or medical intervention was performed

At the same time, it is necessary that the signature of the medical personnel who performed these manipulations, as well as the informed voluntary consent be present for medical intervention;

#3. Contain terms that will be understandable to the patient when making appointments and recommendations

A good medical practice requires omitting abbreviations and complicated terms when notes are intended for a patient.

#4. Contain the signature and date under the entries that were added, as well as the date of any changes and corrections

It’s becoming crucial if we talk about complaints and lawsuits. We all know that without a signature and a stamp any document is just a piece of paper.

#5. Follow the principle of continuity of care

If any other specialist continues to perform work on your current patients, make sure all personal information in his medical record is structured and well-stored, including x-rays, test results, printouts and clinical findings.

#6. Contain the refusals

For various reasons, patients can refuse to take medicines, to be hospitalised, etc. Make sure your notes contain these refusals very clearly.

#7. Be labelled correctly

We highly recommend implementing an indexing system within your medical institution in order to save time and perform effective communication with staff and patients.

Moreover, during the onboarding process, newcomers, especially assistants, must be trained to use this system.

#8. Be destroyed properly

Always follow the retention period. It varies according to the type of record and the county the document was issued. Generally, the retention period is 8 years.

But remember! Some records are to be stored for life.

If these requirements are met, the documentation will protect the doctor from complaints as well as lawsuits. Even so, they often have no grounds. It’s better to prevent the situation than to fight it.

Electronic Medical Record Keeping Saves Your Time and Nerves

NHS Records Management Code of Practice recommended medical organizations to move towards digital patient information in 2021. These recommendations are quite understandable. The electronic format of medical communication is easier to store, track and to be audited. And additionally, it doesn’t worsen the quality of care, but makes it even higher.

But how is it really organised?

The electronic health record will be an indispensable tool for every successful medical institution in 2024, whether it is a private or public clinic, hospital, or laboratory.

In order to maintain electronic documentation, software is used to store and process personal data. Likewise, the medical institution has the right to choose. Each organization decides for itself whether to switch completely to electronic document management or to combine the record partially with paper records. If necessary, this does not prevent the patient from providing the requested documents in writing.

Almost all medical documents can be converted into electronic form. First, this concerns documents about the patient's health status and his treatment. Among these documents are the patient's medical record, the conclusion, certificates, extracts, and referrals.

With the help of EHR, you can not only collect, process and store up-to-date patient data (medical history, visits, payment history, confirmation letters, etc.), but also effectively manage all processes in the clinic, control the financial and marketing part of its activities. Both the medical and administrative staff are able to plan their work, communicate with patients, and analyze all the data received faster and more efficiently.

Some software makes it possible to set up an online medical portal to create a patient's personal account, where they can make an appointment or receive test results.

Moreover, the software provides access to reference books ICD-10, premade answers and required fields that help speed up the writing of the records during the appointments. You no longer need to write long notes, because the entire appointment can be entered into the medical history in a few clicks.

Last but not least, you get access to more than 60 ready-made templates for all specialties, such as examination protocols, questionnaires, treatment forms, and referral letters. Any patient of any age or with any medical condition can benefit from these features.

You will soon see and receive many enthusiastic reviews about your practice if your employees find it easy to work, they are not busy filling out unnecessary paperwork, and they spend time with patients.