Medical records management is the process of collecting, storing, and organizing patient health records. All medical institutions are required by law to keep accurate records for all patients.
The recordkeeping system must store and protect patient information by maintaining confidentiality and privacy. Medical records provide a historical account of your medical treatment.
They can be used to diagnose a variety of medical conditions, provide care, ensure quality, and possibly save your life.
Medical records also support the medical billing and coding process for reimbursement as well as being a source of post-autopsy analysis. Here are some important components that make up a medical records management system:
The Importance of Medical Records
Medical records are a fundamental component of every patient’s care and they are an important part of the billing process.
With this being said, any medical institution should have a sound records management system in place that accurately tracks all patient information.
This is because it helps hospitals provide better care, ensures quality standards, and can potentially save your life.
Types of Medical Record Systems
The first component of a medical records management system is the type of medical record system. Medical records management systems can be classified as paper-based, computer-based, or hybrid.
Computerized systems allow for easy retrieval and distribution of information and are often easier for patients to understand.
Paper-based systems are most common within small medical facilities that do not have the budget to invest in expensive technology.
Hybrid systems combine the efficiency of computerized records with the accessibility of paper-based records.
The Necessity to Maintain Country and Privacy Laws
—The need to maintain country and privacy laws.
—An updated database that can store the latest technology.
—Provided security measures to protect data and patient privacy.
—An efficient system that is able to integrate with a variety of technologies.
The Confidentiality of Patient Information
One of the most important components of a medical records management system is the confidentiality of patient information. Unless you’re an authorized user, it is unlawful to possess, use, or share any patient health record without authorization. Details that are not generally disclosed include:
-Social Security number
-Race or ethnic origin
-Date and time of birth
-Place of birth
-Other names by which known
-Height and weight (if over 18)
-Eye color, hair color, scars and other physical characteristics
Medical Records Policies
Medical records exist to protect the confidentiality of patient information. The medical institution is also obligated to comply with any privacy and security laws.
Medical records policies are essential in safeguarding the institution while making sure your health information is protected.
Policies can outline what information is collected, how it’s stored, who has access to it, and how long it’s kept.
They may include other aspects such as who has the right to amend or delete data, should guidelines change in the future.
Types of Medical Records Management Systems
The type of medical records management system for your institution depends on the number of patients and the scope of services.
There are two types:
(1) a manual system, which is often used in small medical offices; and
(2) a computerized system, which is more common in large hospitals.
Manual systems may be an electronic file folder or a filing cabinet with labeled tabs.
Filing cabinets are often found in office buildings, where all the files are stored together. Computerized systems usually consist of computer software that stores all patient information and provides the ability to retrieve information quickly.
Computerized systems may also be used in small offices. The information is stored on a computer and can be accessed by multiple users.
Most of these systems are designed to meet the needs of a specific type of healthcare facility.
They are usually designed to store medical records electronically and provide a variety of tools to assist with medical record keeping.
Medical records management is an important aspect of healthcare, especially in the United States, where so much documentation is required by law and insurance companies.
The quality and amount of documentation has increased over the years as the number and complexity of insurance reimbursements has increased.
Electronic Medical Records Management Systems
Electronic records and medical records management systems have been in use for years. The digitization of medical records has a number of benefits, including the ability to track patient data, monitor quality of care, reduce paperwork and errors, increase efficiency, and provide accessibility from any location.
Electronic files offer a more accessible alternative to paper records that are difficult to manage. Paper files can be misplaced or lost in the shuffle of patients or damaged by water or fire.
The electronic medical record is also more secure than paper-based systems as they can only be accessed by authorized individuals with an encrypted password.
Electronic medical records management systems may contain all your health information in one place and make it easy for you to view your entire history at any time.
Online Medical Records Management Systems
Online medical records management systems or electronic health records (EHRs) provide easy access to medical records and offer many benefits. They allow you to securely store your medical records in a centralized location.
This is important so that other providers can access them at any time, even if they are not affiliated with the main institution.
EHRs also allow you to share your health information with others, such as family members and caregivers, who may be assisting with care for you.
Patients can sometimes have direct access to their own information through an online account and can even add new information when needed.
Patients can also benefit from a secure messaging system where they can communicate with healthcare professionals about their health.
This can be especially helpful for patients who do not have access to a telephone and want to keep in touch with providers. They are also helpful for patients who live in remote areas and may not be able to travel easily.
A medical record management system is a system that records, stores, and tracks patient data. A medical record management system can be a stand-alone or network-based software that manages the recording, storing, and tracking of all information related to patients. There are many different types of medical records management systems available, so understanding the need for a medical record management system and the types available will help you find the right one for your healthcare organization.