Accuracy of a document in a healthcare facility is of utmost importance. It is because it carries importance regarding the patients health. This article talks about how healthcare organizations can keep their records accurate.
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.
With this article, we will discuss those factors and later on provide a substantial solution that will aid in accurate record keeping.
So read ahead…
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.
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.
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.
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.
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.
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.
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:
There are primarily two reasons why medical records are maintained within a healthcare industry. These are:
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:
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.
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.
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.
Using VisionERA would free up substantial time for the primary caregivers and empower them to serve the patient better.
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