The Importance of Medical Record Accuracy

Medical charting is a process that begins the moment a person receives medical care and is continued through a person’s lifetime. The documentation of a medical record can start when a person enters a health care system, such as a hospital, doctor’s office, home-health care, nursing home, rehab facility or any other type of medical setting.  Most often, a facility will request permission to get copies of previous medical records so the staff has a complete and detailed record of health information.  Have you ever thought about what would happen if a hospital or doctor’s office was not able to get the information or the information was flawed?  This is just one of the many reasons why the medical profession has begun using EMR software, electronic medical software.

 Though the methods of medical charting will vary, there are many aspects of medical charting that are universal.  Some commonly used medical charting sections include; admissions paperwork, history and physical information, orders for medication and treatment, treatment record, medication record, procedures, tests, consultations, consents, flow charts, care plans, discharge orders and insurance information.  When there is no room for error and patient information needs to be treated with the utmost respect and confidentiality, medisoft clinical software can remove the guesswork from the equation.

 The above general categories may be further divided by each individual facility for their own documentation needs and purposes.  For example, a chiropractic office may have a special section for back injuries and testing, or a hospital has a section reserved particularly for labor and delivery, x-ray reports, blood tests, operations and many other things. Additionally, such things as allergy information and do not resuscitate orders may be in a prominent manner.  If a hospital does not know about allergies or final wishes of a patient, it can compromise quality of care or in the worst case scenario result in death.  It is responsible for an institution to make sure the accuracy of medical records is never compromised, having EMR software takes the guess work out of errors by updating and ensuring accuracy is maintained.

 When a person’s healthcare information is compromised, the results and consequences can result in patient fatality and lawsuits.  Having the proper and correct information is imperative, particularly during hospitalization and treatment..  Any health care company can depend on Medisoft clinical software to make sure every bit of history on a patient record is 100% accurate the first time and every time.