Good medical recordkeeping is critical to better understand the health condition of a patient. With accurate medical information, a cross-disciplinary medical assessment will be easier.  

For instance, when seeking a second opinion, your current healthcare professional will have to assess the erstwhile physician’s diagnosis and check prior test results to come up with either a concurrence or a conflicting prognosis. In cases of referrals to other specialists, the medical expert will have to check your previous medical records and diagnosis to seek important medical information. 

Accurate medical recordkeeping is the cornerstone for the provision of adequate medical care. This article explores the basics of medical recordkeeping, its importance, as well as its benefits.  

Access To Medical Records

In the United States, medical data and information protection are overseen by the Health Insurance Portability and Accountability Act (HIPAA). In essence, it dictates the appropriate sharing of protected health information between and among health professionals, medical staff, and medical insurers. Before medical workers other than your physician can access the records, it should be authorized by the patient as expressed in writing.            

A patient has all the right to access these medical records by maintaining a personal health record. Instead of keeping the records in your doctor’s clinic or office, you’ll have to maintain your medical information on your own. The benefit of keeping a record is you’ll have immediate access to important data anytime. 

Medical records may be accessed through a physical paper file, computer software, or mobile app. In these cases, healthcare providers should have scanners for medical records in uploading digital files.

What Types Of Information Should Be Included? 

There’s no universal rule or format in taking the medical details of a patient as it varies from one healthcare professional to another. Some advanced hospitals have electronic patient information and monitoring system, but many still rely on paper to make clinical notes.     

As a general rule of thumb, patients’ records should reflect the following:  

  • Personal information 
  • Reasons for visiting
  • Medical findings
  • Abnormal test findings
  • Diagnosis
  • Treatment details
  • Recommendations 
  • Medications prescribed and administered 
  • Drug and other forms of allergies
  • Instructions relayed to the patient
  • Recommended date for next visit  
  • Patient’s medical history

Do’s And Don’ts Of Recording Medical Details 

If you’re a healthcare provider in charge of placing entries and keeping accurate medical records, here are some of the things you need to keep in mind: 

  • Create dated and time-stamped entries
  • Write down objective comments and observations 
  • Document any nonfulfillment of doctor’s instructions and the reasons for such action
  • Ensure informed consent is understood and signed  
  • List down brief minutes of communications with the patient, family members, or other medical staff about the patient. In some cases, the hospital may need to provide medical translation to the patient
  • Jot down any reaction or opposition to proposed care or management of the patient’s case

On the other hand, here are the things you should avoid:

  • Abbreviations 
  • Personal or demeaning comments 
  • Terms subject to various interpretations
  • Deleting clinical notes, making it obscure  

The most important element of recordkeeping is accuracy. If you made a mistake in the entries, just mark the wrong entry with a single line, record the correct details, and affix your signature beside the entry.   

Basic Principles Of Good Medical Recordkeeping  

Managing the content and keeping the medical records of a patient is strictly limited by pertinent laws in all countries. Medical workers and facilities have the legal obligation to adhere to these following principles:

  • Accuracy And Clarity Of Medical Information

All medical professionals should create accurate and legible records. Doctors are notoriously known for their bad penmanship, and this should be avoided as much as possible when writing down medical information to maintain comprehensible records.

  • Patient Data Confidentiality And Protection

As mentioned, laws are covering medical confidentiality and data protection in each country. The universal rule, however, is medical confidentiality applies to everyone. Hence, no information can be shared unless a patient’s consent is sought and obtained.

  • Access To Medical Records

Only the hospital personnel and patients are authorized to have access to medical records. There are strict rules before others can obtain, process, and share any entry contained in the records. 

Benefits Of Accurate Medical Recordkeeping

Detailed clinical records can facilitate proper exchanges of relevant information among medical practitioners and patients, as well as their families. Also, it can provide the following advantages:

  • Contribute to patient’s quick recovery
  • Promote better case management 
  • Encourage proper diagnosis and treatment
  • Make data available for accountability
  • Could be used as informational evidence in courts

Conclusion 

Proper medical recordkeeping provides relevant information among professionals and patients. It’s important to be practiced at all times because misinformation could lead to the patient being deprived of correct diagnosis and appropriate medical care. Consider these guidelines in maintaining accurate medical records. 

Cite this article as:
Editorial Staff, "A Guide To Medical Recordkeeping," in Medicalopedia, April 27, 2021, [Permalink: https://www.medicalopedia.org/9697/a-guide-to-medical-recordkeeping/].