Keeping patients’records, their history, personal and contact details, etc., is section of any healthcare professional’s practice. Most healthcare practitioners are employing a paper filing system to record and store their patient histories and details. Why? Simply, because that’s how we’re all taught to take case histories and record information supplied by our patients.
Even today, most universities and colleges still teach students to record their patient’s information in paper form. Why? Well, there might be some advantages to using paper, though thinking about them is not so simple, nevertheless, it’s an easy task to flip through the pages of paper and put relevant information side by side to compare the changes in a patient’s condition.
The benefits of storing these records electronically however are many and an easy task to see. For instance, there’s no need to store files in filing cabinets – just think of the amount of space that filing cabinets occupy in leading office. Easily and quickly find a patient’s record in a matter of seconds; store almost an endless quantity of information all on your computer/laptop and the list goes on.
One of the very most significant advantages is as it pertains to quality care of your patients. The key to improving ones effectiveness in treating confirmed condition would be to have the ability to compare previous treatment approaches, their results and effectiveness. To do this with records that have been stored in writing is nearly impossible. Why? Because once a practice is up and running these day there are several hundred records in your filing system and finding all of the cases that offered confirmed condition gets very time consuming.
Using an electronic medical record system however is a much quicker and more effective means of doing research into your case histories and treatment approaches. No matter just how many patient records you’ve, it will now get you only seconds or perhaps minutes to locate all of the records that you’ve for confirmed condition, it is then super easy to compare and contrast the different treatments you’ve used and quickly find the therapy approach that has worked most often.
That is gold, because it not merely saves you time, but will allow you to to fine-tune a specific treatment approach for a specific condition.
Less duplication is another advantageous asset of using an electronic patient record management solution, because if the device was created well, then wherever you will need to include your patient’s details, they’ll automatically be there. So, once you’ve entered the patient’s information into the Details section, it will automatically take the Treatment Program the Receipt/Invoice and any chapters of the software.
Additionally there are some less obvious benefits to using an electronic medical record management system. Ab muscles foundation of any medical consultation is a complete medical case history. Diagnoses are based on accurate histories and just a complete, detailed history will lead to a correct diagnosis, treatment principles and treatment prescription. It is therefore important that your software provides a systematic means of entering information in order that little if any opportunity is missed in obtaining all the mandatory information which will then lead to a correct diagnosis.
Any medical history includes four aspects of enquiry:
Asking the individual about their family and personal medical history and their presenting symptoms;
Listening to the individual – that is a location that’s often overlooked, however, the potency of a patient’s voice, for instance, or listening for wheezing, coughing, tremors in the voice, nervousness, etc., can offer clues about what may be involved in the patient’s pathology.
Physical examination – again that is often overlooked for many reasons, but should form a built-in section of any initial case history.
Looking and observing your patient while they walk into your treatment room, for instance, can inform you much about their musculoskeletal integrity. A practised eye will get postural and structural imbalances, regions of pain and so on.
These four key areas need to be there before you every time you see an individual, so that you don’t have to flick through pages and pages of written information or go from one screen to the next.
An excellent electronic system also needs to allow you, as a physician, to entre this sort of information systematically each and every time you visit a patient. That’s the only way that consistency ever taking could be assured. Obviously if the practitioner does not fill in the info, the real history is likely to be just as incomplete like any system was used, however, the fact software offers the blank space with a heading will help the practitioner to keep in mind to entre the pertinent information.
The benefits of using an electronic way to record and manage your patient’s information are many and far outweigh the old hard copy way of taking and storing your medical records. That said, additionally, there are advantages and disadvantages of different electronic systems.
For instance, using cloud-based or online systems means you’re relying on being able to access the Internet, which may not always be accessible, and is not as secure as storing the info on your physical hard disk protected by passwords. If Apple’s iCloud could be compromised than any Cloud could be compromised and that’s too risky. Furthermore, a standalone application that’s on your laptop works anywhere, anytime, provided your personal computer works. This is very important, because there are times that the net is down, or you’re in a dark spot (if your doing home visits).
Another big problem is that many software programmes are too complex. If you’re going to begin using an electronic system the past thing you want to do is to possess to pay a lot of your time learning and programming the system. All you want to do would be to open the applying and start using it. Unfortunately, the situation with most of the available software solutions is they’ve not been created by practitioners. While that’ll not initially seem a disadvantage, it soon becomes obvious once you start using them in the clinic. They are generally cumbersome, complicated, overly complex and you quickly lose oversight once a few windows and pop-up menus etc., appear.
The best system works just like you had the paper file before you. Everything you want to look at could be on one page on the screen, the same as it can be before you on a table when putting several items of paper side by side. Ideally, all your notes regarding an individual should be there to see, there shouldn’t be a have to switch between windows or having to possess multiple windows open at the same time for you to complete a history and other task.
Physicians are human beings and therefore fallible. We get tired, stressed, over worked and as a result we could make mistakes. An individual record management solution that systematically helps practitioners to sort out their job of consulting with an individual, be it a follow-up or new consultation, is an important tool in today’s busy, modern practice and one that we cannot afford to ignore.