How to Keep Accurate Patient Records

Keeping accurate medical records is an essential part of patient care, but keeping those records accurate and up to date can be quite a challenge. The very nature of medical records can make proper tracking difficult, and the fact that such records are so highly personal only adds to the challenge. Fortunately there are some practical ways for doctor's offices, hospitals and medical clinics to accurately track patient information and make sure that every patient gets the care he or she needs.

Things You'll Need

• Database software
• Patient information
• Dedicated staff members
• The Right Training

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Instructions

• 1

  Keeping accurate medical records is an essential part of patient care, but keeping those records accurate and up to date can be quite a challenge. The very nature of medical records can make proper tracking difficult, and the fact that such records are so highly personal only adds to the challenge. Fortunately there are some practical ways for doctor's offices, hospitals and medical clinics to accurately track patient information and make sure that every patient gets the care he or she needs.

• 2

  Assigning a unique identifier to each patient is essential for the accurate tracking of medical records. Giving each patient a unique identifying number is the best way to make sure that records are updated accurately and in a timely manner. For security purposes, this unique identifier should not be the patient's Social Security number. Instead it should be a unique numeric or alphanumeric code. Other identifying information, such as the patient's first and last name and their date of birth, should also be part of the master record, but the unique identifier should be the key.

• 3

  Database software such as Microsoft Access has been designed to handle large quantities of complex data, making it a perfect choice for electronic patient records. Since Microsoft Access is part of the Microsoft Office suite of products, many medical offices and hospitals will already have the program installed. Setting up a table with the unique identifier for each patient, along with the patient's name, address, date of birth and other important information, is a great way to get started. In addition to its simplicity and ease of use, databases created in Microsoft Access can be easily exported to other formats, making it easy to share information with insurance companies, doctors, hospitals and other health-care providers. There is also specialty tracking software on the market, and this specialty tracking software can provide excellent benefits for large medical offices and other institutions.

• 4

  All of the fancy software in the world will be useless if the staff at the hospital, doctor's office or medical clinic is not properly trained on how to use it. Before any electronic records tracking goes into place, it is important to put firm policies and procedures in place regarding the updating of patient records. In most cases, it would be best to assign a handful of key staff members to enter and update patient records throughout the day. It is important to have enough staff cross-trained on this data entry to cover illnesses and vacations, but this critical job should be limited to the most qualified members of the team. It is also important to have detailed written instructions available to all staff members who will have this responsibility. This kind of documentation will also be very valuable when training new staff members.

• 5

  Online storage can greatly simplify the process of tracking patients and keeping their information secure. By keeping medical records online, health-care providers can ensure that all data is accurate, while at the same time eliminating much of the paperwork that threatens to choke the system.

  Devices such as smart cards are often used by medical institutions to verify patient identity, provide medication information and keep an accurate record of past surgeries and health problems. Patients also can carry their own electronic medical records in the form of flash drives that can interface with the hospital's systems. These electronic storage devices provide an easy way to store and secure this vital data, and many patients are already carrying these medical records everywhere they go.

• 6

  When patients enter the hospital they are generally equipped with special bracelets that are coded with important information such as date of birth and name. The bar code on these bracelets is also encoded with information on the patient's current medical condition, as well as medical history, drug allergies, past hospitalizations, drug allergies, current medications, past surgeries and other imprtant information. Medical staff can make the most of that information and avoid medical errors by verifying both the patient's full name and date of birth before administering any medical care.