Perils of poor medical documentation techniques

For years Doctors kept handwritten notes, and caregivers retained paper charts for our patients. That has all changed in recent years with the digitization of medical documentation. Unfortunately, many of us have grown complacent and often deal with the information in ways it was not intended, or are not as careful with patient's records as we should be. Here are some examples of areas where we have failed and ideas where we can improve.

In the old days we would review a returning patient's medication records, ask if there were any new or different symptoms, and monitor every step of an examination. Today however we can simply click a button and every previous answer is automatically filled in. health information technology online classes While it can be tedious, it is necessary to properly review a patient's record each time they visit and any inaccurate information removed.

With digitized medical documentation and typewritten notations we are able to avoid many of the mistakes of the past involving illegible writing. This was particularly a problem for medical transcriptionists and pharmacists. But now, with such problems a thing of the past, we have a new peril - easy shortcuts. One of them involves the copy/paste method of repeating information for the sake of ease. Frequently this is done to save time, but it can have significant negative consequences for the patient, as well as the insurance company that is billed for the visit.

It is also easier for people and institutions to request copies of a patient's medical documentation. The process has sped things up, but the level of security has not met up with the same pace. Every day we hear stories of unauthorized agents who have gotten a hold of a patient's medical records. In these cases we need to make sure the patient is properly educated about any releases that they sign and the consequences of so doing.

The digitization of medical records is a great technological advancement, but we must make sure we use it as it was intended, and always put the patient first. medical documentation, health information management, onlinetraining healthcare