How to File Medical Records in Nursing Homes

Nursing homes are health-care facilities that offer rehabilitation, skilled and long-term care for patients who reside in the facility. Medical records are files kept on each patient and include a variety of information. Some information included in the file is medical history, medication lists, treatments, allergies and personal demographics. Keeping accurate and up-to-date medical records is necessary to run an efficient facility providing patients with the best care possible. Filing medical records properly allows them to be accessed quickly and allows patient information to be available when needed.

Instructions

Filing Medical Records

• 1

  Electronic medical records are used by physicians to keep track of patient information.

  File medical records electronically. Medical records are often kept in both electronic and hard--paper--copy. Electronic filing is possible with the help of computer programs designed to keep accurate medical record files stored electronically using a computer system. Health-care providers can enter information directly into the computer or transcriptionists can be hired to input medical information from a paper file into an electronic file. Medical records filed electronically can have restrictive access set, which means an individual would need the correct password to access the information in the file. Electronic medical records are used in nursing homes allowing various health-care departments and providers to access information when needed.

• 2

  File hard copies. Nursing homes often utilize paper medical records as well as electronic. Paper files allow for the inclusion of nurses' notes (progress notes regarding a patients condition, treatment and care provided), physician orders, test results and prescriptions. Treatment and medication schedules are included in the paper version of a patient's medical record and can be accessed by nurses and doctors when needed. Medical records can be filed and stored in a room with limited access that allows the information to remain private. Filing paper versions of medical records gives nursing homes a backup system should problems with an electronic filing system occur.

• 3

  Keeping medical records organized helps the nursing home run more efficiently.

  Keep records organized. Organized medical records help nursing homes run efficiently. Nursing homes have the option of filing medical records in a number of ways including by patient name, medical-record number or primary doctor. Filing the medical record hard copies according to the patients' primary doctors allows all of the doctor's patient files to be pulled easily each time the doctor is in-house to perform rounds. Filing medical records by medical-record number helps the billing department, which uses numbers rather than patient names to file claims with insurance companies. After the medical record is no longer needed, file the record in the appropriate place to assure ease of access the next time the file is needed.

• 4

  Keep medical records available to those who need access. Electronic medical records are available on each computer that shares the correct program allowing access to medical-record files on each patient. Some programs allow multiple computers to access one file simultaneously while others may permit only one computer at a time to view the records, which may help assure the file is kept private. Electronic filing may allow multiple departments--such as a physician and his billing department--to view the file at once.

  Hard-copy medical records are available to those in need of the file and can only be seen by those who physically have the file in hand. This simplifies file privacy but may make it difficult if more than one person needs the file at the same time--which may occur during a medical emergency involving these scenarios: the nurse needs the file to copy information to send with the patient to the emergency room, the physician needs the file to see test results and progress notes and the EMS crew needs to view the patient's medical history and medication list.

• 5

  Fast access of medical records helps health-care providers spend more time with patients.

  Access medical records conveniently. Electronic medical records use computer programs that allow various levels of file access. For example, a physician may be granted full access to the medical record by using a special password when logging into the system. Meanwhile, a billing specialist will be issued a password granting access to only the information in the medical file that pertains to insurance and billing matters. Hard-copy records should be stored in a room that is both convenient and has limited access. Door-lock systems that allow entrance only to those who have the proper key card, key fob or numeric password can help assure medical records remain private and secure.