The paper medical
record system presently signifi...
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
How the Paper
Medical record was created
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
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.
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
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
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.
Paper Medical Records in Healthcare organization
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.
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.
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.
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
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.
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
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.
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,
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