Why You Should Organize Your Health Records
A standard, accurate health record should be legible and clear to understand. It should at a minimum contain:
- Medical history
- Examination findings
- Provisional diagnosis
- Any other agreed diagnosis
- A management plan including the recommended tests, treatment, and prescribed medications.
Health records should be customized to include the personal details such as age, blood pressure, weight, hormonal balance and physical status/abilities.
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Previously, doctors maintained patient medical records mostly to remind them about their condition during subsequent visits for checkup or diagnosis/treatment. Now the clinics are becoming a dominant form of health care and a patient might not find the same doctor during each visit. It is vital to allow any physician to take over the patient's treatment by referring to the records for consistency.
Benefits of Organizing Health Records
Allows accuracy of patient data and diagnosis
Accuracy is crucial to health care. Every year thousands of patients die because of preventable medical mistakes. Medical errors are the third leading cause of death after heart disease and cancer something that you can prevent by organizing health records. Organizing health records ensures the information in health records is up-to-date, accurate and inclusive.
Some healthcare facilities have different specialty clinics within their premises. The health data for most people is at various doctor's offices and hospital facilities. Harmonizing and organizing the information into one personal health record allows emergency personnel to quickly find vital information in case of emergency when the patient is unable to provide personal medical information. Data on conditions, ongoing treatments, previous hospitalizations, past surgeries, medications and drug allergies is essential in guiding health personnel on the best actions.Health records can even be more helpful if they contain information on how to contact your doctor or family if there is need to clarify something regarding your health.
Enhances communication and patient
Accurate health record guides a nurse or physician on the patient's condition and to determine what to discuss. A personal health record allows direct communication for a lesser time as there is no need for the patient to narrate a long medical history without guarantee of recalling everything. Health records even allow a physician to think of possible interventions as part of treatment even before engaging the patient in a conversation. For instance, if the PHR shows that a patient has diabetes, a doctor will have plans to check the level of blood sugars and make interventions if necessary alongside treatment for other illness.Well organized health records make caregiving to the elderly, physically/mentally impaired and those with conditions that hinder coherent discussions to be more efficient.
Saves time and simplifies access to health records
Organizing, monitoring and regular updating of a patients' health record allow the person who needs the data to find it fast and find clear, accurate information. Simple to reach health information saves practitioners from spending much time and effort when finding patient details. It also eliminates the need for unnecessary duplicate tests that the patients underwent in the past. Duplicate tests and procedures are one of the highly wasteful spending in healthcare.When information on blood type, vaccinations, allergies and past procedures helps medical professionals to provide fast, efficient treatment when they can find all the essential details in one convenient record.
It is essential for healthcare providers to organize health records well. They are vital for doctors to make accurate decisions about the patient during other visits, emergencies or when traveling.Organizing and securing health records in electronic form helps in attaining clarity, accuracy, and security. Using online resources is essential if there will be a need for frequent sharing of information with other providers.