Recent improvements patient healthcare are the result of many factors: scientific breakthroughs, medical innovation, and technological advances. Medical records fall into the last category; they are a portal through which a physician and other medical staff can step into the history of a patient to learn about prior care, understand current diagnosis and status, and subsequently create a treatment plan. Medical records have long been vital tools in patient care, and current technologies are bringing medical records into the 21st century through innovative software and hardware computer programs. As a healthcare professional, you should understand that the basics of medical records remain the same and its purpose is unchanged, regardless of the platform in which you interact with a patient’s healthcare history.
What Are Patient Medical Records?
Medical records are a combination of both self-reported patient information and a physician’s notes on diagnoses, care, and treatments. These histories involve a variety of information about a patient’s health history and personal habits, including:
Significant illnesses and medical conditions, including documentation on lab findings, diagnoses, and treatment plans.
Biographical data including any history of alcohol use, drug abuse, and smoking, in addition to physical exams, allergies, medications, and any adverse reactions.
Preventive therapies such as immunizations and screenings.
Paperwork to document services performed by medical professionals including dates, times, attending medical personnel, admittance and discharge reports, prescriptions, and any other related medical and lab reports.
Until recently, all of this data was paper-driven. This low-tech format made medical records more prone to error, omission, and loss. Thankfully, medical records have entered the digital age. Technological advances have given rise to more thorough databases that can be searched for patient information instantaneously while reducing the human error quotient.
Why Are Medical Records Important?
How can you know where you’re going if you don’t know where you’ve been? This question is particularly apt for the topic of medical records. As digital medical records databases continue to grow, healthcare will become more cost-effective and result in improved patient outcomes. Medical professionals using data-driven medical records will be on the cutting edge of providing patient care; using these tools, they will be able to catch human error, track therapies, monitor effectiveness of treatments, and make predictions about outcomes throughout the entire course of a patient’s lifetime. With respect to the profession of medicine and malpractice, using digital medical records in your office allows for increased oversight and lowered liability. While medicine will always be an art that relies on personalization and the human touch, technological advances will allow you to take your practice to the next level of safety and effectiveness.
Remember, as a medical professional, it is your responsibility to not only provide care to patients, but also to keep thorough, methodical records of their symptoms, diagnoses, and treatments. Without this follow-through, any physician who subsequently treats your patients will not be able to provide the best care possible, and you’ll find yourself ethically comprised. Take full advantage of the usefulness of your patients’ medical records. Too often, their lives depend on it.