Medical records are as necessary for the practice of medicine as medication for the effective treatment.
The primary objective of medical record keeping is to maintain accurate records of a patient's condition and treatment in order to provide timely and quality care for that patient.
Maintaining accuracy of medical records is vital in patient care, however, the accuracy of medical records and keeping them up to date marks not less than a challenge for the staff. Also, since it is highly personal this adds to the challenge as we know patient records serve as communication tools as well as legal documents. Any Patient Record may become evidence in accordance with Indian Evidence Act. Insurance and other claim settlements. Also, it has a very important role in investigations of murders, assault, rapes and dowry deaths.
They also play an important role in patient and staff education and can be used for quality control and research. The records include patient's family and medical histories; subjective complaints; examination results; test results; treatment plans; reports of consultations and hospitalizations; record of drugs prescribed.
Today, computers play important role in medical record keeping. In addition to billing records, providers can purchase software programs which create and maintain substantive patient medical records.In 1992, the Computer Based Patient Record Institute (CPRI) was formed by a coalition of health care organizations for promoting and developing the use of computerized record systems. This group takes care of the problems that arise from the use of computerized systems so that many benefits of the paperless record will not be lost.
ASSIGNING UNIQUE IDENTIFIER
1. Assign a unique identifier to each patient for the accurate tracking of medical records. After giving each patient a unique identifying number records are updated accurately and in a timely manner. Other identifying information, such as the patient's first and last name and their date of birth, should also be added to the master record, but the unique identifier should be the key.
UNAUTHORIZED ACCESS TO PATIENT RECORDS
2. Software used must protect against unauthorized access or alteration of the record, and unauthorized duplication. There are many software systems require passwords, security codes or key cards, and even fingerprints to assure access. Many contain internal tracking systems to trace every entry and inquiry by individual.
USING SMART CARDS
3. Nowadays,devices such as smart cards used by medical institutions to verify patient identity, medication information and to 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 the vital data, and many patients are already carrying these medical records everywhere they go.
In addition to this, the staff should also know the guidelines for how to correct and update a patient record and how to legally release it to a third party by obtaining written consent from the patient.