Wondering how to maintain good clinical records? Good record-keeping practice is an essential part of any business. In healthcare, though, professional documentation and record-keeping play a more crucial role and have heavier consequences than scrambling to find which files to pull up. The sheer number of patients and the endless conditions and symptoms they present can also complicate matters. There are a few ways to mitigate the risks of improper clinical records—and accurate, professional medical transcription is at the forefront.
So, let’s talk about the importance of good clinical records and how transcription can help medical practices and healthcare professionals keep their patient records spotless.
In this article, you’ll learn how:
- Access to complete and accurate medical records allows healthcare providers to make informed decisions, ultimately improving patient outcomes and facilitating continuity of care.
- Accurate medical records are crucial for operational efficiency in healthcare settings. They prevent the need to scramble for information, saving time and reducing administrative burdens.
- Professional medical transcription companies like Ditto Transcripts provide the most effective way of maintaining good clinical records through accurate, customizable transcripts that can be integrated with any healthcare system.
Definition Of Healthcare Records And Documentation
Aside from a stethoscope around the neck, doctors and nurses are often associated with the image of taking notes on a clipboard or a medical chart. Not surprising, since various studies point to the significant amount of documentation that healthcare professionals do in the course of their duties.
Now, healthcare records and documentation are the collection of documents and information gathered to assist in the patient’s care. These pieces of information were classically gathered through physical sheets of paper. However, technological advancements have made it possible to input these details digitally.
Electronic healthcare records (EHRs) and electronic medical records (EMRs) utilize computer systems to facilitate the easy recording and retrieval of patient information.
Not all systems are easy to use, though, and certainly not everyone has the skills to use them properly. Transcription services can help mitigate the burden of EHR/EMR recordings; more on that later.
Typical patient medical records include some, if not all, of the following:
| Category | Description |
| Patient Information | Personal details that include name, age, gender, contact information, and medical history. |
| Medical History | Past illnesses, surgeries, medications, allergies, immunizations, and family medical history. |
| Clinical Notes | Detailed notes from healthcare providers, including doctors, nurses, therapists, and other professionals involved in the patient’s care. This may include observations, assessments, diagnoses, and treatment plans. |
| Test Results | Reports from laboratory tests, imaging scans (such as X-rays, MRIs, and CT scans), and diagnostic procedures that may include relevant clinical findings. |
| Medication Records | Information about prescribed medications, dosages, frequency, and duration of use. |
| Treatment Plans | Documentation of treatment regimens, therapies, surgeries, and other interventions recommended or performed. |
| Progress Notes | Updates on the patient’s condition, treatment response, symptoms changes, and any complications or improvements observed over time. |
| Consent Forms | Records of patient consent for medical procedures, treatments, and sharing of medical information. |
| Billing and Insurance Information | Details related to medical billing, insurance claims, payments, and reimbursement. |
The Importance Of Maintaining Good Clinical Records In Healthcare
Any healthcare provider worth their salt would prioritize meticulous care of medical record keeping. Let’s discuss why.
Improving Patient Care
Medicine is a complicated science, and any practice that can help make it easier for everyone should be enforced.
Good clinical record keeping, for example, allows doctors to review and approach patient conditions systematically, using readily available data to tick off every possible reason for their current state and improve the eventual outcome.
Medical records can also provide insight on a macro scale. Comprehensive histories and tests can help identify trends, track the effectiveness of new treatments, manage public healthcare concerns, and provide data points that can be used to improve current processes.
Continuity Of Care
Accurate and comprehensive medical records are important because, let’s face it, people need more than one doctor in their lifetime.
Patients might move to different locations, seek second opinions, or be referred to specialists for different conditions. Regardless of reason, doctors need access to all relevant medical information to provide quality patient care.
Operational Efficiency
One of the best ways to maintain smooth operations despite many moving parts is to facilitate good communication between the parties involved.
Hospitals and other healthcare settings can benefit from well-organized and accurate medical records, as there is no need to scramble for relevant information. Easy access and complete records free up precious minutes or hours from administrative tasks, giving medical professionals more time to focus on what’s more important.
Trust Between Healthcare Providers And Patients
Have you ever had a doctor you didn’t trust with your information? Or have you ever felt that you were put through the wringer just to get your medical history and information ready? It’s not an edifying experience.
Trust is a fundamental aspect of healthcare; without it, we might as well consult WebMD for diagnosis. Good medical records help foster trust between patient and provider and improve patient outcomes.
Regulatory Compliance
Healthcare is highly regulated because issues in any aspect of the medical field can lead to lost lives. That’s why several legal and regulatory standards, like HIPAA and HITECH, are in place to enforce secure clinical record-keeping.
Clinics and hospitals found to violate the various strict medical guidelines are at risk of lawsuits and heavy fines. To be clear, the guidelines are not limited to what is included in patient medical records; they also pertain to how they are kept.
More importantly, doctors and hospitals don’t just have to worry about HIPAA coming after them for maintaining poor medical records.
Legal Protection
Case in point: Anthem, Inc.’s 2015 system data breach led to a HIPAA violation and a class-action lawsuit. The final settlement bill was $115 million—and that’s just regarding security.
Issues with medical practice or records can lead to legal action from affected patients. Physicians maintaining good medical records can potentially use them as protection against negligence or medical malpractice claims.
Good medical records also help with informed consent issues, risk management, proof of communication, and regulatory compliance, all of which work to maintain professional standards.
Billing And Reimbursement
I don’t like to think about medical bills if I can help it. I especially don’t like to think about them when I know that medical billing errors are far more common than everybody thinks.
Maintaining quality medical records is an excellent way to avoid costly medical billing mistakes—both for your patients and in the form of complaints and lawsuits. There is no need to fret if you’ve incorrectly billed an appendectomy patient for an unsubstantiated cranial CT scan. It might sound funny when you read it; unfortunately, mistakes like these do happen.
The Consequences Of Inaccurate Medical Records
Quality healthcare aside, issues with maintaining accurate clinical records can lead to many ugly consequences. We touched upon some of them in the previous section; this time, I’ll lay them out in detail so everybody knows what is at risk.
- Compromised Quality Of Care: Hippocratic Oath notwithstanding, fumbling the potentially life-saving care for a patient due to problems in paperwork has to weigh heavily on anyone’s conscience. Even a wrong dosage or medical abbreviation on a chart can compromise a patient’s health.
- Legal Issues And Regulatory Compliance: Doctors who maintain incomplete or inaccurate information are at risk of litigation and heavy fees. Anthem Inc.’s case proved that in no uncertain terms.
- Financial Impact: Even at the lowest levels, fixing medical record errors can cost doctors significant money. Insurance claims can be denied, lawsuit settlements can bankrupt the business, and even repeat or unnecessary tests can drain the hospital’s coffers.
- Damage To Reputation: Who wants to work with doctors they can’t trust? “No one,” is the answer. And without patients, the doctors in question wouldn’t have much of a practice.
Common Challenges In Keeping Good Medical Records
Sure, proper medical documentation is important. However, we must live in the real world and realize that medical documentation is not as easy as it sounds.
Here are some of the issues medical professionals face regarding patient medical records.
- Human Error
- Inconsistent Documentation Standards
- Time Constraints
- Lack Of Training For New Systems
- Security And Privacy Issues
- Limited Manpower And Resources
- Physical Storage
Common Issues With Medical Transcription
Outsourcing medical transcription to trusted providers is a good way to address the issues of maintaining good medical records.
Unfortunately, there are a lot of mediocre transcription providers out there who either lowball their clients or offer “advanced” AI transcription solutions that can’t even breach 90% accuracy.
Such low-quality transcription services come with their own set of headaches, such as:
- Human Error (again)
- Formatting Issues
- Delayed Deliveries
- Tech And System Integration Issues
- Skill And Relevant Training
- Confidentiality Issues
- Costs
- Inaccuracies Due To Use Of Automated Transcription Programs
How Ditto Transcripts Can Help With Maintaining Complete And Accurate Medical Records
Ditto provides medical transcription services for hospitals and healthcare facilities throughout the US. We know how hard it is to maintain good clinical records, so we’ve built our service around fixing the problems our healthcare providers face.
We stand head and shoulders above the competition by offering our clients the following benefits:
High Levels Of Accuracy
Everyone makes mistakes. Even as simple as blank spaces can affect the quality of the medical transcripts.
That’s why we’ve polished our transcription and quality control processes to ensure that every mistake gets caught before it even has a chance to affect any patient outcome. Our 100% human, 100% U.S.-based transcriptionists guarantee 99% accuracy in every project.
Flexibility And Formatting Options
You also don’t need to worry about formatting and guidelines when you receive your transcripts from us. Simply give us a sample format or style guide, and we’ll follow it like gospel. It’ll be like we’re working right there with you.
Turnaround Time
Get your transcripts STAT. We offer 4-hour turnaround times for rush projects to streamline your workflow and reduce operational downtimes.
EHR/EMR Integration
Reduce the burden of new training for your medical personnel. Our medical transcripts are structured to be used with an HL7 interface to auto-populate EHR and EMR fields.
Security
Ditto is a HIPAA-compliant medical transcription provider, and we are 100% committed to data security. We use top-of-the-line encryption, redundant network filters, updated firewalls, and non-disclosure agreements to protect all information you send us.
Don’t believe us? We have testimonials from past clients, including RN Lauren D, who says, “I was happy to find a medical transcription company that stays up to date on security, and HIPAA, and HITECH compliance.”
We’ll make sure you won’t be Anthem Inc 2.0.
Cost-effective Options
No need to bankrupt your facility to get high-quality transcription. Ditto offers various economical options with different turnaround times to fit every budget.
Organized Delivery
There is no need to keep ungodly numbers of file cabinets in your office when you can keep them all on a computer. Clients can access our cloud-based repository to view and retrieve their completed transcripts.
24/7 Customer Service
Chatbots don’t run our customer service—we’re all humans here. We take the time to understand your requirements and will gladly assist you with technicalities or answer any questions.
Want a quick case study? “Getting in contact with the account manager in the hospital would take hours and sometimes days. I never had a problem getting in contact with Ditto. They understood how time-sensitive and crucial my dictations are.”— Dr. Steven B, Neurosurgeon, University Hospital.
Ditto Is Your Next Partner For Maintaining Excellent Clinical And Patient Records
Transcription’s multi-layered benefits can easily mitigate the issues and challenges of keeping good medical records. All you need to do is find the right partner—and Ditto Transcripts is all you’ll need.
Take advantage of our free trial to see why we’re the best in the industry, or call us for any and all questions regarding medical transcription.
Ditto Transcripts is a HIPAA-compliant, Denver, Colorado-based transcription company that provides fast, accurate, and affordable transcription services for hospitals, clinics, facilities, and individual practices of all sizes. Call (720) 287-3710 today for a free quote, and ask about our free five-day trial.
