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How to Maintain Accurate Healthcare Records

Published: April 30, 2021
 

In healthcare, the most important files you’ll ever handle are patient medical records. They tell the story of each patient’s medical condition—what their diagnosis is, what treatment they’ve received, and what doctors they’ve seen. They include notes from doctors, X-rays, test results, immunization reports, and other important medical documents and info. Accurate medical records are critical to patient safety and wellbeing. They foster better communication among healthcare providers, improve patient care and can help to save lives. But how do you ensure that accuracy is maintained across the board, by everyone? Start with your own best practices.

Tips to Ensure Accuracy

Every medical record will be different, just as each patient’s medical history is different. But all good medical records should include the following:

  • Patient Identification—This includes the patient’s name, birth date, and social security number or government ID.
  • Medical History—This includes past diagnoses, treatments and medical care, as well as a list of allergies.
  • Medication History—This tells the physician what medications a patient might be on, what works and doesn’t, and what might cause an allergic reaction.

Some other best practices you’ll want to follow include:

Ensure Healthcare Records Are Legible

Although medical records are now electronic, there may be handwritten notes from the doctor or nurse that need to be scanned into the file. Make sure they are clearly written and easy to read. If there’s something that’s illegible, get clarification and update accordingly.

Sign the Notes in Every Healthcare Record

Every note entered into the record should be signed and dated. Even if they are electronic, make sure they include a digital signature and are stamped with the date. If there’s space left on the signature line, add a single line over it so the signature or documentation can’t be altered.

Don’t Scribble in the Notes

Make a mistake on a handwritten note? Don’t scribble over a misspelled word or use whiteout. Just cross out the error with one single line and continue writing. If you make a factually inaccurate mistake on a digital document, add an amendment. Do not alter it or destroy it and start over.

Keep All Healthcare Documents in Order

All documents should be placed in chronological order to show that the patient’s care has continued. Each doctor’s visit should be recorded separately. Use as much detail as possible. It’s better to include too much than not enough.

Be Objective with Healthcare Notes

Remember to be both professional and objective in your note taking. Don’t include any stereotypical comments or any statements that aren’t factual.

Properly Store Healthcare Records

Store all medical records properly. Storage is just as important as the files themselves. Make sure that you have back ups of the files on hand, that they’re password protected, and can only be accessed by the people who are authorized to view them.

 

If you think you’ve got what it takes to keep medical records in order, you may be a great candidate for a career in Medical Billing and Coding. The Associate of Applied Science in Medical Billing and Coding at Charter College is available to AK residents and can help prepare you for an entry-level career in the field in as few as 15 months. Call 888-200-9942 or fill out the form to learn more now.