Why is it Important to keep Accurate Records in Healthcare?

Healthcare witnesses a series of documents on a daily basis. Ideally, these records are the recorded history of the patients admitted to the hospital. There are various factors because of which it becomes a collateral task.

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With this article, we will discuss those factors and later on provide a substantial solution that will aid in accurate record keeping.

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So read ahead…

Who is Responsible for Maintaining Records in the Healthcare Industry?

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The responsibility of maintaining medical records has always been disputed between the patient and the hospital. However essentially, it is the responsibility of the hospitals to do so. It is because medical records are primarily considered the property of a hospital. 

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Adding more it, it is the responsibility of the doctor providing care to maintain records under his/her authority. The doctors make sure the authenticity of the data in the document and is signed by them. A record that isn’t signed by the treating doctor has no legal validity. 

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Upon the request of a previous patient, the hospitals are liable to provide the necessary records within 72 hrs. Hospitals can also charge a certain fees for administrative purposes and cost accrued because of miscellaneous activities such as photocopying,etc.

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Tenure of Maintaining a Medical Record in the Hospital

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Preserving a medical record is of utmost importance. However, no hospital can maintain a particular record forever. Yet, there are no definite guidelines for the same. The tenure can range from 5 years to 11 years depending upon the recommended time mandated by the state government. These records are maintained from the last date of treatment of a patient or his/her death. One important thing to note is that for minor patients, this time is 23 years in states such as Nevada.

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Methods of Record Keeping in Healthcare Industry

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The U.S government has been actively promoting the use of EHRs (Electronic Health Records). It is for the same reason even today, the records are maintained primarily in two ways i.e paper-based and digital.

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Post covid-19, there has been a push in digitalization leading to higher adoption rate of EHRs. Yet, there are still exceptions to its adoption because of challenges such as training cost, maintenance cost, start-up cost, etc.

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However, the use of EHRs in Healthcare has slowly become the primary method of maintaining medical records. Below are the different types of EHRs used by hospitals:

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• Physician Hosted Systems: In this type of system, the physician is responsible for procuring and maintaining the system. The system is hosted on a physician's server.
• Remotely Hosted Systems: In this time of system, the data provided by the physician or the hospital is stored and maintained on a third-party server.
• Remoted System: The purpose of this system as the name suggests is remote access. These are of three types i.e. subsidized, dedicated, and cloud. Subsidized, the physician shares the responsibility of maintaining records on the hospital's server. A dedicated system shares the data with a vendor and the physician has access to it. Lastly, a cloud based system allows the physician to store data on a vendor's server that can be accessed using the internet.

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Reason behind maintaining accurate records in the Healthcare Industry

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There are primarily two reasons why medical records are maintained within a healthcare industry. These are:

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• Scientific Evaluation: Maintaining medical records of a patient helps in scientific progression of finding a cure or a better cure to an ongoing ailment. The treatments provided are recorded and therefore provide much help during research. Also, it helps the government strategize better considering the overall wellbeing of its citizens in terms of health.
• Legal Binding: In case of any accusation towards the hospital or the treating doctor, having proper medical records helps in case of a court trial. A medical record establishes the treatment provided by the treating doctor helping the hospitals justify that they provided the right treatment.

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Challenges Associated with Maintaining Accurate Records in Healthcare Industry

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It’s a previously established fact that the medical records are authorized by the treating doctor. Although, the work of preparing documents and maintaining them is done by the nurses. A study was conducted by a government organization ncbi (National Center for Biotechnology Information) for finding the challenges that nurses face during record keeping. Those are:

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• Lack of Time: Nurses have to go through a series of micro tasks while providing. Each of these tasks are noted in the medical records. Simultaneously providing care and documenting is difficult because the primary modus operandi of a nurse is to provide care first. 
• Increased Patient Movement: Nurses often run short-staffed despite the number of increasing patients in the hospital. It adds layers of complexity to the nurses work. Adding to it, it was mentioned in the survey that the nurses lack time even after the clinical procedures are provided to the patient and are simply overworked because of their imminent responsibilities.
• Inadequate Supply of Recording Material: One peculiar challenge that was mentioned during the study was the inadequate supply of material for recording the medical activities.

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The combination of all these challenges often lead to cognitive load in the nurses. It leads to human induced errors that fortifies the sanctity of the medical record. Oftentimes, these errors are compounded and can become a huge problem for the healthcare organization.

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VisionERA- How it can help Healthcare Organizations in Maintaining Accurate Records?

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VisionERA is an IDP (Intelligent Document Processing) platform. It provides automation capabilities for various document processing use cases including use cases such as patient onboarding, patient records management, EMR (Electronic Medical Record) maintenance, medical billing, etc.

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Hospitals today still rely on paper-based records that are manually fed to the system. This work of feeding the data is either done by the doctor or the nurse which shouldn’t be the case. It is because their primary responsibility is providing care. However, VisionERA can easily extract data from the wide range of documents used during the treatment and feed them directly into the EHRs. Unlike humans, the output from VisionERA is not prone to error because of its inability to have cognitive overload. Also, it can simultaneously validate the existing documents and make sure that your documents are error free and correct.

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Using VisionERA would free up substantial time for the primary caregivers and empower them to serve the patient better.

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There’s more to VisionERA. Want to learn about it, and see it live-in-action? Simply, click on the CTA below or click here.

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