75Health EHR Software warrants accurate and comprehensive medical charts as well as cloud-based record maintenance for safe and secure access.
The complete record that contains all clinical data and medical history of a patient, medical chart includes demographics, diagnoses, vital signs, treatment plans, medications, problems, progress notes, allergies, immunization details, lab results, and radiology images.
A medical chart consists of the medical notes created by physicians, nurses, lab and radiology technicians, or such other team member that manages a patient's health. Complete and accurate medical charts are essential to ensure systematic and comprehensive documentation of patient's entire health information.
What are the Information Included in a medical chart?
Medical charts ideally consist of almost all records about every medically relevant detail of all the events about a patient since his or her birth. These events include diseases, medical conditions, minor and major illnesses, and growth details. The basic idea is that a medical chart must provide any clinician a clear understanding of all the things that have occurred to the patient previously. This proves critical for helping providers in diagnosing the current ailments and disease states.
Medical Charts generally include the following:
- Medications and allergies
- Surgical history
- Social history
- Family history
- Obstetric history
- Developmental history
- Immunization details
- Medical encounters
At the time of medical encounters, medical charts necessarily contain all and any summations that are related to the patient's care; these may include the following:
- Primary complaint
- History pertaining to present illness
- Progress notes
- Physical examination
- Evaluation and plan
- Orders and prescriptions
- Test results
Access to a medical chart
Healthcare providers who are involved directly and the patients are entitled to access to the medical charts. Patients are the owners of medical charts; they have the right of ensuring the accuracy of the medical charts and granting access to other parties. Patients are eligible to petition providers for amending inaccuracies, if any, in the medical charts.
How does the Electronic Health Record (EHR) help healthcare?
An EHR ensures that medical charts are accurate and complete. Being the digital version of the medical chart of a patient, EHRs prove very helpful. A good EHR System or Software alerts caregivers about any incomplete, missing, or inaccurate medical charts.
The EHR is a digital, real-time record enabling authorized users to access available information securely and instantly. EHRs render themselves to be shared among different healthcare providers and medical organizations such as specialists, laboratories, pharmacies, emergency health facilities, and imaging centers, apart from workplace and school clinics. This makes it possible to have information from everyone involved in the patient's care. EHRs have the potential to streamline and automate providers workflow as well.
The ability to assist other activities related to care either directly or indirectly through different interfaces such as quality management, evidence-based decision support, and outcomes reporting is another benefit. EHRs help in tremendously improving patient care in several ways; a few have been given below:
- Enabling instant access to critical health information, reducing treatment delays and duplication, offering information to patients for taking better decisions.
- Reducing medical errors, improving the clarity and accuracy of medical records, and coordination of treatment and diagnosis among providers.
- Allowing patients to access their own medical records and view lifetime health trends that empower them to arrive at proper decisions.