Medical records are the document that explains all detail about the patient’s history, clinical findings, diagnostic test results, pre and postoperative care, patient’s progress and medication. If written correctly, notes will support the doctor about the correctness of treatment.
It is very important for the treating doctor to properly document the management of a patient under his care. Medical record keeping has evolved into a science of itself. Medical records form an important part of the management of a patient. It is important for doctors and medical establishments to properly maintain the records of patients for two important reasons. The first one is that it will help them in the scientific evaluation of their patient profile, help in analyzing the treatment results, and plan treatment protocols. It also helps in planning governmental strategies for future medical care. But of equal importance in the present setting is the issue of alleged medical negligence. The legal system relies mainly on documentary evidence in a situation where medical negligence is alleged by the patient or the relatives.
Despite knowing the importance of proper record keeping in India, it is still in the initial stages. The lack of basic health data renders difficulties in formulating and applying rational patient care and disease prevention.
A good medical record serves the interest of the medical practitioner as well as his patients. It is very important for the treating doctor to properly document the management of the patient under his care. Medical record keeping has evolved into a science.
Objectives of Maintaining Medical Records:
- Monitoring of the actual patient
- Medical research
- Medical/dental or paramedical education
- For insurance cases, personal injury suits, workmen’s compensation cases, criminal cases, and will cases
- For malpractice suits
- For medical audit and statistical studies
With paper medical records, all you need to get started is paper, files, and a locked cabinet to store all the documents. There’s a reason why paper medical records were an industry mainstay for several decades. It’s easy to pull up information from a file, examine previous notes and medical charts, and record new observations. If the information is written clearly, there can be fewer complications in reading charts and notes on paper.
Paper records are advantageous in this sense: a physical file with all previous charts and medical history neatly sorted in one place. Plus, the data can be physically passed around from one person to another seamlessly. Of course, all of this depends on the previous notes being neatly written, properly organized, and readily accessible.
Paper medical records need physical space for storage purposes. What do you do if there’s a fire that wipes out all your physical files? Or a moth infestation that, quite literally, eats up all your data? Physical files, once lost, are impossible to recover.
Paper medical records mean you need a manual written process which is both time-consuming and comes with a higher degree of error. If you’ve ever attempted to read a doctor’s notes, you’ll know that the writing isn’t always legible and therefore can be hard to interpret.
While paper-based records can be easier to customize, it also means that the layout and format of information can be inconsistent from one record to the next. When paper-based records have different layouts, it extends the time needed to get the information needed for a patient.
Paper records don’t have built-in version histories and audit trails. Knowing who made which edits and additions require that the physician signs the records each time. If changes are made, it’s not easy to locate where the changes were and who made them.
When it comes to deciding between papers vs. electronic records, there are a few things you must take into consideration.
Electronic health records are far more secure than paper records as they’re not at risk during a catastrophic event. It’s also easier to retain accountability in electronic health records — each entry log is consistent with a specific individual.
An electronic system doesn’t have these problems — records aren’t handwritten, so the legibility issue isn’t an issue at all. Plus you don’t have to search for patient files in a physical cabinet — the software does that for you (instantly).
Electronic health records have a consistent format that healthcare providers can get accustomed to. Electronic health records ship in a customized format that helps with things like legibility & accuracy of medical data. Paper-based records can involve human error and a loss of data integrity.