In today’s ever-evolving business landscape, almost every industry has started to rely on some form of documentation to streamline processes, and the healthcare industry is no exception to this trend.
Patient records management is becoming an important area that is prioritized by an increasing number of doctors and medical practitioners to help keep track of patients and their medical records.
These medical records form an essential part of the overall management of a patient. For doctors and medical entities, it is of paramount importance to properly maintain the medical records of patients, to be able to analyze the diagnoses results, plan appropriate treatment, and more.
However, as with any other system, there are always the chances of mistakes or errors that can come in while managing the patient’s records. In this post, we’ll discuss some of the most common errors in patient record management and how you can address them.
Top 5 Common Errors To Avoid In Patient Record Management
Several common errors can happen during patient record management. These include overlooked medical records, inaccurate diagnostic results, transcription mistakes, records, incorrect medication instructions, inappropriate abbreviations, and more.
Here we are discussing the top 5 errors that you need to avoid while managing patient records.
1. Lack Of Clarity
Patient records and other medical documentation carry some critical information pieces. This requires the records to be clear, specific, and detailed enough to describe the patient’s condition and treatments with higher accuracy.
However, there are various instances when using ambiguous terms or very few details can make these records harder to interpret and lead to incorrect diagnoses or treatments.
It is, therefore, important to use clear, transparent, and precise language during patient record management. This also means giving complete descriptions of the patient’s treatments or medications.
2. Illegible Records
One of the common challenges in patient records management is making sense of medical abbreviations or another person’s handwriting.
It makes it hard for doctors and clinicians to interpret medical information and may lead to errors in diagnosis, treatment, or other critical medical decisions.
The best way to avoid this error is to use standardized forms and terminology when maintaining patients’ records to ensure legible and accurate documentation. The key benefit of this will be consistency throughout the patient records.
3.Not Storing Digital Copies Of Patient’s Medical Records
Keeping up all the patient’s medical data in digital or electronic format gives you a better idea of your patient’s needs. Also, it makes the process of patient records management smoother.
The ideal way to do this is to have patients’ records in a centralized place, including their health status, drug prescriptions, and any other updated information about their health.
Several patient management software programs also available can help you with the cumbersome task of record-keeping by storing all your medical records in an organized manner. Leveraging these software programs is one of the simplest ways to avoid common patient record mismanagement.
4. Not Keeping The Records Up-To-Date
Another common error while managing a patient’s records is outdated or old details. For smooth patient records management, the patient findings, test data, diagnoses, history, and treatment must all be up to date and in chronological order to show the updated status and continuity of care.
This data also includes other important details such as patients’ contact information, email addresses, and phone numbers. Also, ensure your staff is adequately trained to manage these records seamlessly.
In case you are using patient management software for maintaining records, it is all the more important that healthcare personnel know how to use the software. It is best to conduct training sessions and provide the right resources to achieve this.
5. Patient Identification Errors
Patient identification error is another common issue associated with maintaining patient records. Accurate patient identification is, in fact, fundamental to safe patient care delivery.
Mismanagement of patient IDs can lead to a range of issues, such as injury, wrong treatment, duplicate and disparate medical records, and more.
Leveraging efficient patient management software here can help you deal with all the above issues and eliminate the chances of duplicate and inaccurate patient information.
In Conclusion
Errors in patient records management can lead to severe health implications endangering several lives. One way to prevent these mistakes from occurring is by tackling the issue of patient record management early on.
This should be the priority for everyone in the medical field due to the need for maintenance of patients’ medical records for both safety and regulatory purposes.
One of the best ways to navigate this and execute a highly efficient patient records management system is to select a robust patient management software that can cater to your specific needs. Apart from helping you reduce time and costs significantly, patient management software can also help you improve accuracy manifolds.
Healthplix offers powerful patient management software to give you a secure and safe way to keep patient records that can also be backed up with remote data storage. The platform uses only the safest encryption standards and privacy-safe practices for seamless patient records management.