Contents
- 1 How do you make sure medical records are accurate and complete?
- 2 Why must medical records be accurate and complete?
- 3 Why are complete medical records important?
- 4 How does the electronic health record system work?
- 5 What happens if essential information is missing from medical records?
- 6 Can a patient request a copy of the medical record?
How do you make sure medical records are accurate and complete?
Maintain Accurate Medical Records
- Legible – If your handwriting is not legible, consider dictating your notes.
- Timely – Most electronic medical record systems document the date and time of all entries.
- Accurate – Ensure your documentation accurately reflects what occurred during a patient encounter.
Why must medical records be accurate and complete?
Good documentation is important to protect your patients. Good documentation promotes patient safety and quality of care. Complete and accurate medical recordkeeping can help ensure that your patients get the right care at the right time.
Why are complete medical records important?
Clear and concise medical record documentation is critical to providing patients with quality care, ensuring accurate and timely payment for the services furnished, mitigating malpractice risks, and helping healthcare providers evaluate and plan the patient’s treatment and maintain the continuum of care.
What are qualities of a good medical record?
6 Key Attributes of a Medical Record
- Accuracy of the medical record. The accuracy of the data refers to the correctness of the data collected.
- Accessibility of the medical record.
- Comprehensiveness of data.
- Consistency of information in the medical record.
- Timeliness of information.
- Relevancy of the medical records.
What do you need to know about a medical record?
12-Point Medical Record Checklist : What Is Included in a Medical Record. A medical record is a systematic documentation of a patient’s medical history and care. It usually contains the patient’s health information (PHI) which includes identification information, health history, medical examination findings and billing information.
How does the electronic health record system work?
An electronic health record, or EHR, is set up to ensure that medical charts are complete and accurate. Think of it as a digital version of a patient’s paper medical chart. With good EHR software and EHR systems, health care providers will be alerted to any missing, incomplete, or possibly inaccurate medical charts.
What happens if essential information is missing from medical records?
If essential information is missing, found to be inaccurate or indecipherable, cases may be lost when they could otherwise have been won. Clinical records include a wide variety of documents generated on, or on behalf of, all the health professionals involved in patient care. This includes:
Can a patient request a copy of the medical record?
If the patient or the patient’s living relative (with proper clearance) requests to review the sequestered original records, he/she may do so only in the presence of a service unit employee. Requests for copies of IHS records must comply with federal regulations at 45 C.F.R. Parts 2 or 5.