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Why Keeping Good Medical Records Is So Important

Published: February 24, 2021 | Updated: February 25, 2021
 

Everyone makes mistakes, even on the job. But when you make a mistake with a patient’s medical record, you could create serious consequences for the patient, your facility, and you. Those records document everything about a patient’s health, from what treatments they’ve had to what medications they can and can’t take. That’s why it’s vital to ensure that medical records remain accurate and consistent over time.

What Is a Medical Record?

Ever since 2015, health facilities have been required to keep Electronic Health Records (EHR). These electronic medical records tell the story of your patient’s health. They include information on the patient’s diagnoses, how they’ve been treated, what doctors they’ve seen, and what medications they can and cannot take. They generally include:

  • Handwritten notes from physicians
  • X-rays
  • Tests and lab results
  • Consent forms
  • Printouts from monitoring equipment

EHRs can also include emails between the doctor and patient or communications among healthcare professionals about the patient. All of this information is important for the doctor, patient, and anyone involved in patient care.

Why Do Medical Records Need to Be Accurate?

Accuracy is crucial. A detailed medical record could, in fact, save someone’s life. Here are just four reasons why this documentation is so important:

  1. EHRs Inform the Doctor: A doctor can’t remember every single encounter with every single patient. But they can look through a patient’s record to refresh their memory before a visit. They can find the basic information they need without having to ask the patient questions that they’ve probably answered many times before. This is also helpful if a patient needs to switch to another doctor or see a specialist. The new doctor can find all of the necessary information in the EHR.
  2. EHRs Protect the Patient’s Health: Medical records outline the patient’s treatment plan. If mistakes are made in any of this documentation, it could affect the patient’s prognosis. This is especially important when it comes to medication. Patients can be allergic to medications and some medications can’t be mixed with others. If this information isn’t properly documented, the patient could suffer an adverse reaction.
  3. EHRs Help Move the Billing Process Forward: Medical records provide information on what treatments will be covered by insurance. In most instances, the insurance companies will request access to these records to move the process forward. If the information in an EHR is inaccurate, it could cost the patient a lot of money.
  4. EHRs Protect Your Facility: If a patient threatens to sue for malpractice, a well-maintained medical record could help your case. EHRs are often the first item a legal team will look at in a malpractice case, and if there are any errors, it could put your facility in hot water.

 

The maintenance of medical records is an important job, for the patient, physicians, and your practice. If you’re organized and have an eye for detail, you may be a great candidate for a career in medical coding and billing. At Charter College, we offer an Associate of Applied Science in Medical Billing and Coding that will provide you with knowledge of healthcare law, electronic health records, claim submissions, and more. This program is offered online through our Anchorage campus for Alaskan residents and our Vancouver campus for non-Alaskan residents. Call 888-200-9942 or fill out the form to learn more.