Medical records are important files that every patient must have. Technically, if a patient suffers from a physical injury, medical records make sense because they serve as legal evidence when they file for a claim. These medical records are stored electronically and via physical folders in the medical records section of each hospital. That said, it is important that you keep track of your medical records to make sure that it’s not altered and if there are necessary corrections then it should be done legally.
While medical records can be prepared in a different manner, take note that there are guidelines each healthcare institution should follow to be able to have the most comprehensive medical report. In that sense, let’s show you some characteristics of excellent medical records. Here are they to get you started.
Accuracy and Reliability of the Medical Records
The reliability and accuracy of each medical records refer to the information and data being collected from the patient. This is done during the initial admission of the patient, during medication, and after discharge. Collecting an accurate medical record may be affected by these factors:
- The patient’s emotional and physical health by the time the data is collected
- The healthcare worker’s ability to interview and record the collected data
- The ability to access the historical records of each patient
- The way the data is being charted; and
- The ability of every health professional to keep track of the data stored on a daily basis
The Accessibility and Quality of Medical Records
A good medical record can be accessed easily. Easy access does not mean that anyone can get it. It means that even though these records are being safeguarded by the rules imposed by HIPAA, you and your personal injury lawyers can request a copy of it without any hitch. Aside from that, Medical Record Retrieval Companies American Retrieval are also third-party outsourced companies that can efficiently help you in accessing your medical records and they also can get it without any problems.
Data Comprehensiveness
An excellent medical record should have comprehensive data being collected from the patient. Everything needs to be recorded and at the same time, each healthcare professionals assigned tallies accurately what your medical condition look like.
The Consistency of Medical Records
Each medical record should be consistent. It means that data collected are not altered and deviated from what’s really the exact condition that a patient is experiencing. Also, the integrity of each medical records is kept and by the time you and your personal injury lawyer request it, they remained reliable and consistent.
Promptness of Medical Records
This refers to the ability of the healthcare professional to take note of the necessary data collected in a timely manner. They must record the medical situation of every patient in a timely manner avoiding any alterations and misinformation of the said medical records. This is to ensure that records are not delayed and served right away.