A patient record is one or more documents containing information and documentation about a patient’s health condition, treatment, and care interventions. The patient record includes details such as:
- Personal information
- Allergies and preferences
- Wishes and goals
- Treatment plan
- Treatment options
- Treatment decisions
- Treatments and care
- Health condition
- Meeting notes
Multiple documents form the patient record, where a document could be an image, note, video, or audio file, such as a test result.
All information communicated between healthcare providers and patients is gathered in the patient record, including care plans, alternatives, decisions, implementation, and updates. All conversations, meetings, and advice are documented in the patient record.
What functions does a patient record have?
A patient record serves several functions and should reflect the various stages of a patient’s healthcare process. Its primary purpose is to contribute to safe and appropriate patient care. Additionally, a patient record functions as a source of information for the patient, the healthcare facility, regulatory authorities, legal requirements, and research.
Another crucial function is the ability to collect and analyse statistics from patient records. This statistical data is used for quality assurance in healthcare, research, and development to enhance understanding of various phenomena and trends at regional, national, and international levels.
Documenting information about a patient is necessary to create a treatment plan for the patient in the next steps. The goal is to ensure that all parties involved work toward the same objectives and carry out the agreed-upon measures.
What should a patient record contain?
According to patient data laws, a patient record should include the following information:
- Identity information (name, social security number)
- Reasons for the patient’s healthcare
- Patient’s diagnosis, conducted examinations, and treatments received
- Information provided to the patient and decisions made regarding treatment options
- Information if the patient chose to decline certain care or treatment
- Details about who made entries in the record and the date of each entry
Who is responsible for the information in a patient record?
The responsible healthcare provider ensures that access to the patient record is limited to what is necessary for the patient to receive appropriate care and for healthcare professionals to perform their duties. Internal confidentiality is ensured through technical solutions for authorization and access.
Who has access to the patient record?
In addition to the patient, who has the right to access their own record, authorized personnel also have the right to access patient information. Authorized personnel are those who need to access the information related to the patient to fulfil their job responsibilities.
Who is allowed to read a patient record?
The patient themselves has the right to request their record to read, transcribe, or copy. Patient records are confidential and, apart from the patient, can only be accessed by individuals employed by the healthcare provider who are actively involved in the patient’s care or need access to the information to perform their duties within the healthcare system for legitimate reasons.
When is a patient record needed?
A patient record is necessary to monitor the progress of the care provided, creating an overview and assurance for both the patient and the healthcare provider. By consolidating all the information, opportunities arise to identify areas for improved care and alternative treatment options.
The patient record is utilized before, during, and after a meeting or conversation between healthcare providers and patients, or whenever new information is added. The record is used by the healthcare provider in consultation with the patient and should only be shared with responsible healthcare providers and the patient.
Many smaller clinics either use physical documents or Excel files stored on a shared computer. This is neither secure nor efficient and can lead to documents being lost or accessed by unauthorized individuals.
Do all clinics need to maintain a patient record?
All licensed personnel and individuals with specific authorization to practice certain professions are obligated to maintain journal entries. Other healthcare staff should work in this manner to ensure safe and high-quality patient care. Journal entries should be recorded as close to the time when new information arises as possible. A patient record forms the basis for safe and secure patient care.
Depending on the size and type of clinic/healthcare institution, different types of record-keeping systems are used. Smaller clinics often do not have the same extensive needs as larger facilities in terms of the capacity and storage of record-keeping systems.
What are the benefits of using a record-keeping system for patient records?
Using a record-keeping system makes it easier for all clinic staff to receive patients, as the patient record contains all the information the healthcare provider needs to receive the patient. Not all systems offer the same services, but the following are examples of the benefits that come with adopting a record-keeping system:
- Secure data management
- Increased efficiency
- Patient database – access records anytime, anywhere
- Overview for all staff
- Manage e-signatures for consents
- Digital registration
- Analysis capabilities
- Data security assurance
- Simplicity for staff – more time for patients
- Support on various devices – computer, mobile, tablet
- Improved customer relations
Learn more about the benefits of a simple record-keeping system in our article here. Have you not yet tried MERIDIQ as a free service for your patient records?
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