• Jun 09

    Versio Staff

    Raising the Bar on Healthcare Documentation – What patients don't know

    by  Versio Staff

    Some of the aspects involved in providing quality healthcare include accrediting or approving healthcare providers, offices, and hospitals. There are specific accreditation standards to ensure proper procedures are performed and staffing ratios are met. This process also ensures that medical records are continuously reviewed and up to date in order to assess the effectiveness of any treatments or procedures performed. Improving patient care is the driving force behind standards and regulations in quality healthcare today.

    Quality documentation can ensure the overall patient experience is positive. Patient ratings are being tracked to ensure their expectations are being met. Quality healthcare can be defined in many ways but, ultimately, it is the patient’s story that matters. Whether a patient is coming in for a routine check-up or major surgery, how will the patient rate his or her overall experience?

    Here are some questions the patient should be asking:

    • Did my physician spend enough time with me to answer all my questions or concerns?
    • Why did the nurse or physician ask me questions that they should already know about my overall health history?
    • Do I feel confident that my health record is complete and there will be no hiccups in my upcoming surgery?
    • As a patient, (who may or may not be familiar with the HITECH Act of 2009 and why the government is pushing the electronic medical record) what do I need to know?

    Patients should be aware that many healthcare providers, although medically trained, are not necessarily technically trained. The expectation by the provider when moving from a paper chart or from an electronic medical record to another is that their patient’s past medical information will be available in the new system. Often this is not the case. It is up to the doctor or the nurse to gather the patient’s past medical history during the exam to recreate the new chart in the new system. Is this a good practice? Will the patient recall their full medical history? Can you?

    If the goal of the electronic medical record is to collect patient information in order to provide better outcomes why don’t healthcare organizations do a better job of making sure that the new electronic record is pre-populated with the patient’s current medications, allergies , immunizations and problem lists – at a minimum. Would this make for a smoother transition to the new electronic record? Would the patient’s first visit post go-live be a more positive experience?

    Making the choice of not migrating all of the patient's clinical data can be very impactful when considering patient care and safety, clinician accuracy, efficiency and productivity, and institutional exposure and risk.

    At Versio, we believe that every patient deserves a complete and accurate health record. And as patient portals become more widespread, patient satisfaction will become an issue if great care is not taken to provide the complete and accurate patient story. Our motto is “No Data Left Behind” and we mean it.

    Please consider a short conversation and a demonstration of our unique process for 100% data capture with near-perfect accuracy. This will be time well spent and ultimately a huge benefit to your staff, your physicians, and the patients you serve. Contact us: sales@myversio.com or 253-277-0505

    For additional information regarding our service lines, visit www.myVersio.com

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    Posted in Industry Information, News