Healthcare institutions, including hospitals, private practices, and clinics, are increasingly opting for electronic medical records (EMRs). However, there are specific standards one needs to follow while creating EMRs. For example, all details filled out in the EMRs must perfectly match the paper records. Therefore, any information, no matter how insignificant, must be included in the EMRs if recorded on paper forms.
While digitizing medical records, you must also be careful during data entry to avoid mistakes. Incorrect, incomplete, or missing patient information is a privacy and security concern for both the clinic and the patient.
Going digital has many benefits only if it is done correctly. Here are the six best tips to follow while digitizing medical documents.
6 Best Practices to Create Digital Medical Records
1. Plan First:
Going digital is an easy task if planned before. It is not something that can be accomplished at a moment’s notice. Firstly, decide on the cost. How much do you plan on spending to create these digital records?
This includes the cost of medical record scanning services, buying new tabs or laptops for the in-house staff, and much more. Secondly, figure out whether you want to convert all your records or just a selected few. This will help the transition process significantly.
2. Select Records To Convert:
Here are a few examples of paper medical records that you can choose to convert into digital format:
- Patients notes from previous visits to the doctor
- Forms of new patients
- Patient contact details
- Patient insurance details
- Patient charts that include medical history, lab results, diagnosis, symptoms, medications, allergies, and doctor’s comments
- Result of patient’s first or last medical exam
- Billing information for revenue and reimbursements
- Calendar to schedule patient visits, check-in, and appointments.
3. Hiring a Medical Document Scanning Company:
If you plan to scan all your medical records, you might consider hiring a document scanning company. You can organize all your files and send them to make digital copies of the same.
Choose a company that specializes in scanning medical records and patient charts. Ensure that the company you hire has the requisite technology to convert all the data into a digital format that can be seamlessly integrated into EMR or EHR of any type.
Additionally, if you send paper records over to the medical record scanning services facility, ensure that it is secure. Ask for onsite scanning services if you cannot send confidential documents to their facility, including HIPAA medical records.
If you are low on staff, hire some temporary workers to organize the files for a smooth conversion process. At the end of the day, the options you choose will depend on your budget and how soon you need the digital records.
4. Give Proper Training to Your Staff:
Involve all your employees in this conversion process to ensure no hiccups during the implementation of digital records in day-to-day work. Give your staff proper training to handle digital forms and use EMRs.
Please ensure they are comfortable using the laptop or tablet instead of a clipboard when attending to patients or recording information. They must only resort to clipboard if the EMR goes offline.
5. Take the Time You Need:
Getting used to the EMR system will take time for you and your employees. So, take the time you need to implement the system in place. Proper training and attention to detail will make this transition period smooth and fast. The best way to deal with this situation is to set a timeframe for this implementation.
The best start is to understand the basic functions of the digital system first. Gradually over time, the employees will learn the other parts and features. If your employees have difficulty getting used to the digital patient recording system, consider reducing your patient load by 25 percent for a week or so to give ample time to your staff to learn.
During this time, you can consider doing the following things:
- Segregate your patients into active and semi-active to ease the implementation process.
- Conduct frequent training sessions to clear doubts
- Conduct mock on-hand training to give your employees a practical experience recording patient details digitally.
6. Plan on How to Handle Paper Records:
Now that you have digital medical records plan what you want to do with the paper records. You can either store or dispose of them. However, before making that decision ensure that all the information has been correctly recorded in the digital format.
You can now file these paper records or move them to an offsite storage unit to make space. Older medical documents can be shredded or disposed of depending on their significance.
Going digital helps in delivering better healthcare to your patients. Now, you do not have to waste any more time looking for essential documents. Get everything at your fingertips with digital medical records.