During week four of interviews, I noticed that the majority of facilities have switched over to electronic medical records system. Those using paper system seems to use more steps to keep their records safe and experience more problems. Each medical facility is different with different needs but there are some steps or methods that are the same regardless if they use electronic or paper filing. Facilities using both electronic and paper filing system will experience problems regardless.
After reviewing my interviews and my classmates interviews, every facility seem to experience a lack of information on the patient when a new record is made, trying to find the correct information in the patient’s file, and the lack of the medical staff documenting the information correctly. Those who use electronic filing experience trouble learning the new procedures or upgrades because there is not enough time given to them. Facilities that using paper, often have trouble with patient records getting misfiled.Both electronic and paper filing system encounter problems with patients who have the same first and last name.
Extra steps must be used to make sure the right record is pulled up. Those steps might include asking the patient for verification of their address, phone number, or other means of identity. Privacy is a must in a medical facility.
Patients expect their health conditions or medical history to be and remain confidential. The Health Insurance Portability and Accountability Act is a law stating that all medical facilities and personnel must keep these records confidential.Most facilities keep their records safe by using computerized passwords. Some of my classmates stated that the facilities they interviewed use back systems such as back up discs to store these records in a safe place while others use the HIPPA guidelines. During personal handling some medical offices require authorization to review the patient’s record, some require a password to pull of the patient record, and other medical offices stated they are only allowed to pull one patient at a time so that errors do not occur when entering the patients information.Each facility stores their patient records differently. From the week four interviews, it seems that the medical offices store their record based on the size and type. Some of the interviews stated that a bigger office would either keep it in a large room that is password or badge protected.
Those who use electronic format would use a computerized password. Unfortunately not all records are prevented from getting lost. To recover a lost medical record, some of the interviews using paper method stated that there was no real method for finding a lost record.The facilities I interviewed stated they did not have any particular method but would simply have to re-create a new or call another facility to see if they could fax the information to them. One classmate stated that there was a certain person in charge of lost records. Nevertheless, it seems that most facilities conduct an investigation to find out who was the last to review the record in hopes of finding the lost record.
If a person is no longer a patient of the medical practice, they can decide to have their records faxed over to another site or get a copy of them for themselves.One of the facilities I interviewed charges a service fee to have a record faxed to another place. Even though the record may be faxed to another care giver, the office still keeps the record and these records are kept forever. Some facilities keep them for a certain amount of years or they are shredded. After reviewing the classmates interviews, all the electronic record offices keep their patients records forever. Medical offices need to have policies and procedures to ensure that no rrors are made in a patient’s file, and records are stored properly to prevent theft, or any other criminal act. If the medical facility is using an electronic format, management should give the team adequate time to learn the new procedures. The medical staff should also take their time and make sure all information that is entered, is correct.
Incorrect information can have many negative results, such as slowing the flow of traffic in the office, patient receiving wrong treatments, wrong diagnosis, insurance could even get messed up because codes were not entered correctly.