The transition to an all-electronic office and the management of those records can be tricky, but it is not difficult to learn and eventually master.In this article, you’ll learn about medical records management used in healthcare, and the benefits of a strong records management program. You’ll also gain insight into the evolving practice from healthcare experts.
What Is Medical Records Management?
Medical records management is the part of records management that relates to the operation of a healthcare practice. It is the field of management that is responsible for all records throughout their lifecycle from creation, receipt, maintenance, and use to disposal.
Sometimes referred to as Health Information Management (HIM) or Health Records Information Management (HRIM), medical records management can involve anything and everything about a practice and a patient, including but not limited to a patient’s history, clinical findings, diagnostic test results, pre- and postoperative care, patient progress, and medications.
A medical record can help both the physician and the patient. For the patient, the record can outline one’s history and treatment plan in an easily-accessible way.
For the physician, it can provide support about the correctness of that treatment plan. A good medical records management system can be the difference between life and death if someone needs to check a test, a medication, or make a quick medical decision.
Risks of Unmanaged Medical Records
Not having easy access to potentially life-saving or life-changing health information is a significant risk that unmanaged medical records present. A lack of organization with regard to record keeping can also pose a legal threat. Additionally, when staff are constantly struggling to find things, patients might view the lack of structure and policy as a signal that a practice is behind the times.
Inefficiency can also lead to a loss of productivity, duplication of efforts, or an inability to complete necessary tasks. Billing errors could arise as a result of poor records that ultimately cost the practice money. Paper records also require a physical storage area and can sometimes result in practices needing to purchase additional office space, which can be expensive.
When individuals create their own non-standardized systems, they are exposing an organization to more potential issues. For example, it could lead to insufficient backup plans and increased costs to convert records from formats that adhered to technology that eventually became obsolete. Simply having backups of data in multiple places is pointless if it is not accessible or usable.
Unfortunately, many medical facilities do not see medical records management as a critical or necessary function. As a result, they do not provide training or structure to create an efficient and compliant policy.
Careers and Training in Medical Records Management
Many medical providers make the mistake of assuming that anyone can handle medical records management. This is not the case: It is a specialized and technical field. In some organizations, there are health information technicians who are responsible for compiling and organizing medical records while maintaining confidentiality and security.
There are also health information managers who deal more with the overall health information management structure than the day-to-day data entry. Each organization has different titles and job descriptions with varied salary and certification requirements. As with any skilled type of work, training, certifications, and professional organizations are available.