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Medical Records
Ugh!! Medical records can be the bane of our existence. For many of us, record keeping is an unpleasant chore, a necessary evil in the practice of medicine. The end of a clinic day, when one has to dictate a number of clinical records, can be a real downer.
When one considers that many physicians will have a patient complaint or lawsuit in their professional lifetime, the role of record keeping becomes quite important. In the context of litigation, the medical record is more important than the actions of the physician. If one’s medical care was not documented, then it is seen as not having happened.
There are many other reasons for accurate and timely medical records. Patient care is quite often multidisciplinary and all the professionals involved need to be kept informed in order to maximize quality of care. As a specialist colleague to family physicians, a timely consult letter can prevent visits to the emergency room if a plan of care is outlined. A consult letter can often be a source of education for a colleague, a place where new information and management plans are relayed.
For one’s own follow-up of patients, we need to be reminded of essential details, especially when one is seeing patients infrequently. Relying on one’s memory can be inaccurate at times, especially when one is busy. Most offices have learners and sharing of patients. Clear and well documented records ensure that patient care is consistent between different providers.
The electronic medical record has been a breakthrough in many ways, providing a more legible account of a patient visit. This allows others in a group practice or multidisciplinary care environment to keep informed of the care plans. That being said, one needs to protect the confidentiality of patient information. The CMPA has a large number of publications regarding electronic medical records, including specific resources about confidentiality and email communication.