Patient Record-Keeping Process in Healthcare

According to a survey, on average, nearly a fifth of an organization's patient records are found to be duplicated. These duplicate records adversely affect both patients and healthcare providers. For healthcare providers, these records lead to billing and coding errors. In some cases, it ends up affecting the overall revenue cycle. On the other hand, these duplicated records can jeopardise patient health and safety. These records contain incomplete and outdated information which not only affects the quality of care but sometimes also leads to the physician making the wrong decisions based on outdated or incorrect lab results, allergies and current medications.

To understand this further, let’s watch the next video, where our faculty member, Mr Shivakumar Krishnamurthy, will help you understand the challenges faced by patients and healthcare providers, and discuss ways to mitigate them. 

In this video, you learnt about the importance of record-keeping through a typical patient journey. The journey may start with a consultation with a physician in a primary health care centre, where they are diagnosed and provided an initial prescription. Once the initial diagnosis is done, the patient gets themselves tested in a lab as per the physician’s advice. If the ailment persists, they see a specialist, who often has to go through the entire process if the record-keeping process is flawed. 

Patients and healthcare providers often face challenges in these steps, some of which are listed below:

• Often, previous medical records are missed out entirely or not given importance. 
• These records are often based on the recall capacity of the patients and their attendants. At most times, certain allergies or adverse conditions are missed out. 
• A Longitudinal patient record or a single comprehensive patient record is often unavailable or inaccurate, owing to which the process of diagnosis needs to be started from scratch. 
• A lot of time is wasted during these back and forth steps. 

You also gained an understanding of the issue of fragmented patient records, which can be resolved by implementing a comprehensive EHR/EMR system. This system provides a 360-degree view of the patient to the various stakeholders within the hospital system. 

Such an EHR system should include:

• Clinical history of patients, such as demographics, case history and relevant family history; 
• Treatment history of patients, including past medications and treatments; 
• All the claims made by the patient, which will help in discussing the cost of potential treatment options with the hospital administration. 

You also understood that the administration should consider the following aspects while implementing an EMR system:

• Integration of data within and outside hospital systems 
• Subsequent reporting of data  to various departments 
• Capturing clinical notes and discharge summaries. 

Ultimately, the data belongs to the patients, and thus, while implementing an EHR system, the following considerations must be made: 

• Patients should be able to transfer data if required. This will help the patient to use their previous records if they move to another hospital or city. 
• Privacy and portability standards must be maintained, such as Health Insurance Portability and Accountability Act (HIPAA) and Digital Information Security in Healthcare Act (DISHA). 

In the next segment, you will learn about the patient discharge process.