While Rolf Smith (see quote in the text box on the right) was not an expert on medical records, his wise words do apply to the healthcare industry. Detailed record keeping, including both initial intake and maintenance, are paramount to risk mitigation for healthcare practitioners.
Medical records ensure continuity of care between providers (2). They also act as a means of communication between providers and members. Patient records cover everything from preventive care to treatment, as well as standards and expectations for delivery of care. And while excellent record keeping should be evidence enough that your healthcare practice is doing its best to avoid litigation, a solid audit plan is also imperative to ensure that record maintenance is done properly. Your firm’s records, and your actual recordkeeping practices, will be scrutinized should you ever be sued for malpractice (3). Even outside of a malpractice lawsuit, data breaches are a growing concern when so much PHI (protected health information) is collected by a single source. And data breaches can turn into class action litigations.
While the future lies in EMRs/EHRs (electronic medical records/electronic health records) (4), that does not mean that manual (paper) records are obsolete. And they definitely shouldn’t be discarded. All data that is collected, no matter the format, is subject to privacy laws, and therefore can easily turn into a potential liability.
Accuracy is paramount in recordkeeping (5). Every individual encounter should create a snapshot that stands alone from prior visits (and prior diagnoses). The challenge lies in maintaining this separateness while also creating a ‘big picture’ view of the patient, merging both history and current issues.
Contact us today if you would like to learn more about auditing your recordkeeping system. We know what issues to look for and can uncover them before they become a risk to your practice.