The paper medical record system presently signifies an enormous disintegration of patient health record. Not only it is hard to manage tons of paper work, it increases the cost of the health care system due to information disintegration leading to the adverse effect on the present and future patient health care. Accessibility of applicable data presents unbelievable perspectives such as it decrease clinical errors, and therefore it amplifies the quality of health care provider. It also support health care professionals in their everyday responsibilities and investigate work.
How the Paper Medical record was created
Accurate medical records are essential to patient care in any health care setting. One correct digit in a patient’s Social Security number causes reimbursement problems. An incorrect address or telephone number or misspelling of a name makes it difficult to contact patients about test results and prescription refills. Medical errors are even more disastrous and can cause serious medical problems for patients. Patient files are critical to the facility’s smooth functioning and are vital when referring the patient to outside specialists with whom the facility may need to coordinate with whom the primary care provider may need to coordinate care.
The patient’s medical chart is prepared on or before the day of the patient’s first visit in the medical facility. Paper medical records require the assembly of appropriate file folders, divider pages labeled with identifying tabs, and a number of essential forms to be completed by the patient. Included forms provide demographic information, social and family medical history, previous surgeries, HIPAA guidelines, and release of information details (Engelbrecht, 2005). Often, paper charts include adhesive twin prong fasteners to ensure that sheets of paper are securely held within the chart.
Paper-based medical records are stored in either secondary or primary locations that are normally in the healthcare organization. Records of full medical operations are stored in primary storage facility, and are filed numerically in an attempt to realize efficiency. The filing system of an organization is usually numerical, and is based on terminal digits of the patient’s HRN. A current copy of the Paper-based medical records register should be kept in the folder at all times. This may be the system used most of the time to locate Medical Records but it also provides a system to search should the power fail. Ideally, two colored coded number of stickers are placed on the protruding right hand side back cover, of the medial record cover. These numbers normally match the last numbers on the HRN on the register. The digits that are numbered are colored, and in the case where they are misplaced, then it will show that the charts are misfiled. Ideally, file location can be determined from the color grouping through the use of the last digits of HRN that is written above the colored stickers.
Consequently, in an attempt to ensure efficiency in chart filing system, it is vital for the management to maintain and update the Interim data collection tool at the health centre and notify the information management officer of changes requiring central updating—HRN, given name and surname (Fordney et al, 2007).
Purpose of Paper Medical Record
The purpose of paper medical record is to provide guidelines for maintenance medical activities, its contents, security, and patients’ confidentiality. However, the medical records available should always conform to the set requirements especially the rules and regulations guiding medical records. These laws are structured in federal and State constitution. In addition, it provides a distinct definition of medical information that should be in the medical record.
Consequently, the patient paper medical record is a vehicle that enhances the documentation of actions that take place between the patient and the medical institution. This enables the medical institution to track the patient’s progress and to ascertain the relevant drugs that need to be administered to the patient (Iyer et al, 2006). Patient management has been the key aspect in most of the developing institution, and medical institution is not an exception. Some of the diseases can be communicable, and the paper medical record enables the hospital management to administer measures that will minimize the spread of the disease. As such, patient’s paper medical record has enhanced patient management hence, realizing the medical global goal (Wager & Lee, 2009).
The other purpose of paper medical record is to provide a vehicle for harnessing meaningful medical information to other practitioners should the patient transfer to a new provider or should the provider be unavailable for some reason. In this scenario, the information in paper medical record will be transferred to other medical practitioners in an attempt to realize effectiveness of the whole operation. Medical institutions have always relied on past medical records of individuals, especially from different institutions, in order to diagnose the patients’ ailments. The current trend in the spread of diseases requires an institution to have proper paper medical record, so as to track the patients and institute strategies to combat the ailment.
According to Kirch (2008), paper medical record ensures that medical practitioners are provided with a platform to decide on the appropriate course of actions to be undertaken. The rationale in which a medical practitioner relies upon will demand on the information provided by the paper medical record. As the information contains patient’s history of his/her medical care, the practitioner can analyze the records and implement relevant course of action basing on the information on the medical records. However, the information provided in the paper medical record is sometimes biased and may be favorable to some conditions or patients. Such manipulated information can be misleading and the medical practitioners cannot rely on the data.
Finally, the medical record provides both the clinicians and medical institutions continuity of patient care over a given period. They can easily communicate with other colleagues in the case of referrals and consultation as they have precise information of the patient. With the help of the practitioner’s narrative note, the medical record will ensure that it will be convenient to track the medical record of the patient. A medical practitioner will rely on the documents that outline the process in which it will enhance the patient’s recovery. As such, it has been vital to rely on medical records in order to effectively undertake a continual patient care.
Operation of Paper Medical Records in Healthcare organization
Paper-based Medical records play a vital role in a healthcare organization. Personal health information, in most health organizations, is stored, after being recorded, in the paper format. Ideally, print-outs of laboratory reports, clinical notes (copies), and histories of an individual’s health are vital in a healthcare organization, and are usually part of the paper medical records. The method is quite reliable, less costly, and can be easily accessed without the use of electronic system such as computers. According to Mantas (2002), the most successful paper-based personal Health record includes the hand-held record on pregnancy, which was initiated in 1980s by Milton Keynes. It is currently used across the society.
Healthcare organization relies on medical records in order to initiate coherent patient information. Centralization of business activities have always been a core aspect in many of business organizations. Paper-based medical records aim at centralizing the operations of the organization. The records are normally stored in one central place in an organization as such harnessing for an ease in managing the activities or operations of the healthcare organization. As they are stored in alphabetical order, the medical staff can analyze health of information of a particular patient and decide on the stringent measures to be incorporated into the healthcare organization. However, its operation has been curtailed by the bulkiness of paper-based medical records.
Its operations in the healthcare organization have enhanced the management to harness the trend of patients’ medical care. Clinical notes, which are part of paper-based medical records, enable the medical staff to analyze the medical condition of the patient. The efficiency and reliable of healthcare organization will only be achieved when the medical staff diagnose and treats the patient’s disease through reliance of past medical records. Although it has been argued that adoption of personal health records have been low—from both the staff and the patients—its operations have enhanced success of healthcare organizations in the medical field.
Consequently, like an organization structure, medical records management also imposes the same structure. At the low level is the sub-ordinates staff that ensures that the paper-based medical records are kept safely, and easily accessed when there is need to retrieve the information. It is quite cumbersome to manage files and clinical notes for future reference as there is no defined trend that a patient follows when visiting the healthcare organization. At the peak of the record management is the records manager. The manager is responsible for planning, coordinating, and implementing strategies that can enhance accessibility of the medical records by other medical staff. However, with the increase in number of operations in the healthcare organization, the management has reconsidered the use of electronic medical records that will speed its operations. Technological advancement has fostered for ways to increase the efficiency, accuracy, and reliability of healthcare information.
Problems existing in operating Paper Medical Record System
Paper charts have always been the primary organized method of keeping all available data on patient progress and treatment in one location. This compact storage method is convenient but has several disadvantages, most of which have been overcome by the computerized medical record.
Although patient charts can be copied, keeping more than one copy of a paper medical record is impractical because of storage space and the need to ensure that all records remain completely up to date. The single-record concept therefore prevents simultaneous access by more than one provider and by those who are not in proximity to the paper chart. In addition, when patient charts are delinquent, they are typically sequestered in the medical records department awaiting completion, which then necessitates that providers access these records in that location. Access to charts requires borrowing the medical record, and when lost, this patient data can rarely be completely replaced.
Consequently, accessing a chart has traditionally involved flipping through pages of studies, results, and notes. In order to obtain a chronological sense of a patient’s course that includes their myriad of tests, imaging, and visits, a mental picture must be made after review of each section of the chart. The paper medical record does not incorporate application-specific tools that enable visual organization of the sequence of treatment and assist the clinician to organize, interpret, and treat to patient data. Ideally, data manipulation need not be completed mentally or by jotting down notes. New study types and files formats such as video and even images that can be manipulated, is not possible for paper chart.
Documentation and data collection has also been a major problem facing paper medical record. Entry of data into traditional patient charts is limited to handwritten notes and printed documents. Entering notes is, therefore, laborious and time-consuming and often incomplete because of this inconvenience. Other techniques, such as Electronic Medical Record (EMR), have the advantage of enabling multiple methods of documentation, such as direct typing, transcription/dictation, and voice recognition, which simplify and speed data entry and facilitate documentation. Certain interfaces also impose structure on that data entry either by menus or filed completion, resulting in improved organization (Shortliffe & Cimino, 2006). Additionally, being able to ‘cut and paste’ or use shortcuts allows quick repetition of pertinent data without having to refer a reader to a separate section of the chart they must then locate. Such shortcuts can also pull data from defined fields into the note automatically, speeding up the documentation process and decreasing the risk the data are erroneously omitted.
Jokes about physician handwriting have been present for decades, but unfortunately; are factually based. The impact of an illegible note can vary from something as minor as increased time required to determine the contents of the chart, to errors in prescription and medical orders, causing devastating clinical consequences. Such errors have prompted adverse decision making process that has culminated in increased insecurity on the patients endeavors.
Clearly, institutions that have large numbers of patients, or that have patients with extensive histories, require considerable physical space in which to store paper charts. The paper medical records do not allow far greater information to be stored in a much smaller area. Ideally, when needing to access a paper chart, it must be located, pulled from storage, and transported to the requesting provider. This process is cumbersome and consumes a lot of time when retrieving the required information.
Increased cost of Healthcare caused by Paper Medical Record
A health care facility may scan or microfilm its records itself, provided the facility has the proper staff and equipment, or it may send its records to an outside contract service. However, most of the organizations are currently relying on electronic medical record, as they believe that paper-based medical record is quite costly. Some of the issues that have made the system to be costly vary depending on the size and nature of healthcare facility (Jacko and Sears, 2003).
The cumbersome nature of paper-based medical records has led to the recruitment of additional staff in order to manage the operations in the health care organization. Such an additional staff requires an additional budget. Indeed, with paper-based medical records, the staff needs to understand that the in an attempt to thrive in their medical practices, they must learn to deal with recording each of the patients’ medical status; thereby, requiring large space. In addition, business operations always grow with increase in revenue outlay or increased number of clients. Therefore, when the medical practice grows, the organization needs to increase the storage space for keeping the medical records. This process requires an additional cost in the healthcare organization (Reynolds, 2009).
As paper-based medical records are slow to handle, the management will also change its strategy to working overtime in order to meet the bulging consumer demands. The staff will demand payments for the extra time in office; therefore, increasing the cost outlay for the company. The medical records are often handled by specific individual staff. This means that, upon completion, the staff needs to hand in the records to the other medical staff for analysis and storage. It is clear that the medical records can be easily misplaced or lost depending on the way in which the managerial team is organized. Consequently, the records are often mixed up in the process, making the healthcare organization incur costs in retrieving the files; either through lost time or employing sub-ordinate staff to search for the misplaced medical records.
Consequently, experienced and large number of staff is required to manage the high number of paper medical records in a healthcare organization. Ideally, it is quite a difficult task to manage these medical records. It has been reported that, over the past decades, healthcare organization have incurred costs due to dedicating most of its time in shuttling records rather than attending to client’s needs. Most of the business organizations aim at increasing the revenue outlay for its operations. In shifting the attention from creation of revenues to shuttling of medical records, an organization will create unnecessary costs and not maximize profits. In harnessing smooth flow of operations, organizations have devised ways in which they can attend to the medical records and also meet the client’s needs. This has been through the increase of number of staff; hence, increasing remuneration to the staff.
Finally, filing and finding records for the clients have not only reduced the efficiency of staff, but also the efficiency of patients. This is to the expense of the healthcare organization. Where staff efficiency has declined, the clients or patients will not be willing to attend the medical organization for service provision rather they would prefer other healthcare organizations that are efficient. The longer in which the staff can retrieve the medical records of the patient, the longer it would take for the patient to be served efficiently. Loss of revenue is not always in the concept of many organizations, and there has been need to undertake electronic medical records in order to increase revenue outlay (Glad, 2008).