The importance of patient medical records to the medical field

Patient medical records describe the medical history of a single patient during a specific health jurisdiction. Read the importance of patient medical records below. 

Hospitals are dealing with the lives and health conditions of patients. Good medical systems rely on professional health staff and high-qualified facilities. Without accurate, up-to-date, and accessible medical records, medical care might not offer the best treatment for patients, leading to serious consequences. Besides, good patient medical records ensure the administrations of hospitals can run smoothly.

Many associated records such as X-rays, drug records, and patient registers must be well-managed in custom apps. Keeping the medical data of patients clear and easily accessible makes patient medical records a perfect solution for hospitals. If you are a healthcare provider, maybe you might be concerned about finding a healthcare software solution or hiring software outsourcing services to do this. The article provides readers with the benefits of medical records, concepts, types, and examples.

Patient medical records: An overview

What is patient medical record?

Patient medical record defines who, what, where, when and how of the patient's healthcare during their hospitalization. It consists of the quantities of data and information gathered every day, especially in the healthcare aspect. An increasing number of patients and the rising diseases and symptoms need health organizations to manage numerous healthcare information. When coming to a healthcare software solution, hospitals consider record forms as an integral part of medical practices since it ensures good care for patients.

The patient medical record is a confidential record for each patient related to health professions or organizations. It includes people’s personal information such as name, address, DOB, medical history, and documentation of each hospitalization (symptoms, diagnosis, treatment, and outcomes).

Benefits of medical records for hospitals 

Benefits of medical records to patients

The information transfers of patient medical records amongst offices are less time-consuming and efficient. The hospitalization of patients will be enhanced with more efficient processes and automatic information routes transferring amongst different departments.

Hospital staff tend to make fewer mistakes which somehow affect patient care owing to easily accessible information stored from any department.

The advantages of patient medical records to healthcare providers 

Patient medical records help healthcare providers to process information electronically. It allows hospital operations to move faster and function more efficiently, reducing operational and administrative costs.

Storing patient medical records automatically in a server, especially a healthcare software solution, is a cost-saving approach for any healthcare provider.  Besides, this medical record technology helps secure patients’ information during their hospitalization. Thus, hospitals can hire software outsourcing services to develop a healthcare software solution for their administrative operations.

Quickly accessing the information of patient medical records will reduce medical errors, and even prevent them from affecting patient care.

Concept and types of medical records for all patients 

Information from patient medical records provide essential data for managing patient care, clinical audits and service delivery. Besides, the patient medical records also help collect data regarding ages, symptoms, and treatment for statistical purposes. Here are examples of what to be included in the patient medical records.

*  Clinical notes from doctors

* Discussions with patients (about diseases, symptoms, etc). Maybe use tape of recording for such discussion.

* Referral notes for consultation/co-management

* Histopathological reports/Laboratory

* Images.

* Clinical photographs.

* Drug prescriptions.

* Anesthetic notes/Operation notes.

* Information from monitoring equipment.

* Electronic records.

* Instructions relevant to patient care.

In terms of different healthcare aspects, there are different types of medical records found in healthcare providers. They can be patient history and examination reports, radiology reports, pathology reports, laboratory reports, emergency, therapy, clinical notes, X-ray reports, autopsy reports, etc. There are numerous manual medical records from a medical facility. However, this information widely used will be transcribed in a healthcare software solution. 

The Importance of patient medical records 

Significant challenges of using manual medical records

The sensitivity of medical patients has brought some challenges to manage administrative hospitals. The challenges relevant to patient medical records are storage, access, safety, and security. Hospitals using manual medical records have witnessed storage problems. Besides, access to medical records is one of the most common challenges that patients and healthcare providers face. Sometimes there will be a conflict on the authority and the right of access to patient medical records. To handle this challenge, the US Fair Health Information Practice Act (1997) tried to minimize this friction by making healthcare providers allow patients to examine their medical records. 

Furthermore, the security of manual medical records is another challenge to the person in charge of patient medical records. Cases such as doctors, nurses, medical secretaries, ward clerks, and others should be aware of the safety and security of medical records. With these significant challenges of manual medical records, medical record technology will be a feasible healthcare software solution for hospitals.

Healthcare providers might consider software outsourcing services to develop a feasible healthcare software solution. 

How medical record technology can support patient medical records

The misuse of medical information not only happens in paper-based records but also in electronic-based medical record technology. Electronic tools such as electronic mails, the Internet, telemedicine allow remote use of medical records. In this situation, an effective security system will help limit appropriate access to patient medical records. So that’s why medical record technology can support patient medical records for collecting and storing patient information. 

First of all, patient medical records improve the quality of healthcare and access to information. Secondly, medical record technology helps reduce human errors attributed to illegible physician handwriting.

Moreover, patient medical records might contribute to saving costs in the management of patient records. Last but not least, it improves information sharing amongst different departments, thus enhancing communication of patient information.

Despite its benefits, patient medical records have many challenges. For example, healthcare providers need a significant amount of financial resources to set up a healthcare software solution. Besides, when hiring software outsourcing services to develop a healthcare software solution, hospitals need to hire another party to maintain technical problems and train staff before using. Another challenge of using patient medical records is security. Security problems might refer to the privacy of medical records. Thus, the adoption of medical record technology will prevent this problem from happening. However, the advantages of patient medical records can overcome their disadvantages in general.

Medical record documentation examples 

Sample patient medical record

No.	Information
1. Summaries	Biographical data Critical information  Discharge reports from hospitals  Notes of the consultations & admissions Instructions for patients on discharge Summarizes from nurses
2. Textual medical record	Continuous textual medical record Referrals within hospital
3. Lab results (tissue and body fluids)	Clinical biochemical
4. Organ function	Cardiovascular, senses, locomotor, etc
5. Radiology and other images	Radiological investigations, CT, MRI and others
6. Treatment and observation	Chart summary, anesthesia forms, etc
7. Nurses’ documentation	Nurses’ notes and admission essential reports
8. Other health information	Occupational therapist, physical therapist
9. Correspondence	Admission request forms, referrals, etc
10. Notifications	Public certificates, forms and notifications

Medical record request form for hospital operations

Closings

Patient medical records play an essential part of managing administration and operations within hospitalization. The implementation of patient medical records helps improve the overall patient satisfaction, especially during their clinical consultations. In addition, patient medical records enhance the quality of services except for clinics such as appointments, the prescription process and the referral system.