A critical aspect of any hospital or medical practice is proper documentation.
The main function of ensuring that your records are clear and accurate is to protect your patients.
For a patient, those that are well-maintained and protected inspire their confidence in you, and in the long run also help you get more patients.
Taking good care of your documents may save you from getting involved in any legal hassles as well.
Here are some tips to keep in mind about patient medical records.
Care should be taken to see that excessive charting is not done.
However, the information should be sufficient to ensure that you have met the necessary care protocols and also enough to justify your decision to provide, delay, or change treatment.
Any concerns or complaints made by the patient should also be included in the chart.
Patient history including any allergies he has to drugs and food as well as any prior test results should be noted.
Entries are made by the physician either at the end of the patient's visit, or at the end of the day.
It is preferred that entries be made when the patient is there, or soon after he leaves, to ensure that you don't forget anything that is noteworthy.
Patient medical records should be maintained forever, unless your attorney advises you differently.
Thus information such as patient charts, x-rays, test results and any correspondence should be kept forever.
In case you use shorthand and short forms to take down information make sure you change it and put it down clearly and concisely in the charts.
Physical ones are difficult to maintain and take a lot of space.
If these are destroyed it would cause, not only you, but your clients a problem.
Electronic patient medical records are better as it is easier to have back-up storage for them and they would hardly take any space.
This computer data should be backed up regularly and stored at a different location as well.
Those which are inactive should be carefully stored as well and should be easy to retrieve when needed.
If a patient visiting your practice brings medical data from the past, it is important that you review it and return them once done with.
If for some reason you decide to keep some of the records make sure you make them a part of your permanent records.