There’s no denying that implementing electronic health records (EHR) software significantly enhances your medical practice.
Nonetheless, if you want to reap all the benefits of using an EHR system, having the software in place isn’t enough.
You also want to make your EHR software work for you, and one way to achieve that is by organizing electronic health records to minimize the amount of manual work you need to perform daily.
As a result, you can save time, increase your medical practice’s efficiency, and focus on more important parts of your practice, such as interacting with patients and providing the best patient experience possible.
The doctor should not bear the burden of administrative workload and drown in documents, while he can see more patients and treat them more carefully. The Medesk electronic medical record structures the data in such a way to improve the quality of medical decision-making.Learn more >>
So, in this article, we will share 7 effective tips for organizing electronic health records that will help you make the most out of your EHR software.
7 Tips for Organizing Medical Health Records
Without further ado, here are 7 tips for organizing electronic health records:
#1. Identify Your Information
While some medical information changes often, other data remains the same for the entire length of the patient’s relationship with your clinic.
For this reason, you want to first identify your information and categorize it into two separate groups based on how often you’ll have to update it.
In short, the two types of information are as follows:
- Static information. This type of information rarely, if ever, changes or varies. Static information includes patient names, surnames, dates of birth, NHS numbers, insurance numbers, and such.
- Dynamic information. Based on circumstances, dynamic information changes regularly. It can include appointment dates, medication prescriptions, diagnoses, referrals, and other similar information.
By identifying your information and organizing electronic health records into these two groups, you can effectively save time.
Essentially, organizing electronic health records with EHR software allows you to automate static information input. In other words, you won’t have to enter static information manually each time.
However, when you’re working with dynamic information, it’s best to enter it manually, even if you’re using EHR software. This way, you can prevent any errors and inaccuracies from happening.
#2. Create Comprehensive Patient Records
Organizing electronic health records allows you to create comprehensive patient records that extend far beyond basic patient medical data.
With EHR software, gathering, storing, and organizing comprehensive patient records is easy. All you need is a little bit of prep.
Essentially, even an empty patient medical record includes a set of static information that you can later use to easily generate other documents, such as invoices and medical prescriptions.
As such, to properly create documents in the future, each record should contain the following static information that helps to identify the patient:
- Patient full name.
- Date of birth.
- Contact details.
- Home address.
This static information should be the base of all electronic health records.
However, to create a comprehensive patient record including static information isn’t enough. You also want to add sections that will later contain dynamic information.
Such preparation makes organizing electronic health records much easier. Once you add the sections, you can simply fill them in with patient information and files (e.g. images and laboratory test results) during or after appointments. This ensures that all of your data stays neatly organized.
Here are the main sections that you need to create a comprehensive patient record:
The patient medical history section will include a detailed account of all the medical events related to your patient. A patient's medical history also contains all of the actions previous healthcare providers took, as well as the medical actions you take.
Use these tips for the medical history section to save time organizing electronic health records:
- Organize the medical history in chronological order. This way, you will be able to quickly and easily find any specific information that you need.
- Copy your previous notes to save time. Instead of entering the information manually, whenever possible, simply copy the information from your past notes and comments into your current notes.
Forms and Documents
To create a comprehensive patient record, you also need to include a section that will contain all of the forms and documents you create and use in your medical practice, such as referral letters.
To make organizing electronic health records easier, make sure to sort these documents according to their type. For example, store all repeat medical prescriptions together, separately from referral letters.
Aside from creating and storing your forms and documents, using EHR software allows you to print well-formatted documents in just a couple of clicks. Alternatively, you can save your documents as a PDF file for digital use, if needed.
Transitioning from paper to electronic health records can be a lengthy process.
However, professional EHR software allows you to make the transition much easier.
To upload documents, such as laboratory results and images, you can simply scan the documents directly in the patient record.
This allows you to easily store and view a digital copy of a document without having to download it onto your computer.
Invoices and Billing
A comprehensive patient record contains a full account of your patients’ standing in your clinic.
And, because your patients are also your clients, you want to include their medical billing data in their patient records too.
At Medesk, information about each patient is stored in an individual electronic medical record. It allows you to view all the services rendered to him during the treatment at the clinic.Open the description >>
Including this section in your patient record allows you to:
- Keep track of any debts and pending payments.
- Monitor your medical practice’s financial health.
- Easily produce invoices, receipts, credit notes, and other payment-related documents directly in the patient record.
In other words, effective communication is critical to your medical practice’s success.
As such, when you’re organizing electronic health records, you want your patient record to include a communications log. A communications log helps you to:
- Keep track of any text or email communication with your patients.
- Send and monitor automated booking confirmations and reminders to reduce appointment cancellations and no-shows.
- Write one-off texts and emails to your patients to create a personalized patient experience.
#3. Set Up Smart Data Entry
If you’re looking to make organizing electronic health records a breeze, you’ll need to set up smart data entry.
This will maximize the amount of automated data. As such, smart data entry can boost your medical practice efficiency by helping you effectively save time and effort.
Here are some tools you can use to set up smart data entry and generate excellent documents each time:
- Drop-down lists. Use these to select one option from a long list. Drop-down lists work especially well for ordering laboratory tests.
- Yes/No switches. For direct, closed-ended questions, use yes/no switches. This way, you can effectively conduct patient surveys and questionnaires.
- Buttons. To log in patient symptoms and signs, take advantage of buttons. Buttons allow you to select multiple responses to a single question and systematically review the data.
- Rich text editor. From text to tables and lists, use the rich text editor to organize electronic health records. In particular, the rich text editor tool is useful for generating laboratory results, formal reports, and comments.
- Units of measurement. To log in laboratory results, BMI, and other such data, use the “units of measurement” tool. This allows you to save time finding the exact units you need.
- Drug entry via the BNF database. This tool allows you to quickly and correctly prescribe drugs. Not to mention, you can format medical prescriptions in just a few seconds!
- ICD-10 entry. You can use the ICD-10 entry tool to report formal diagnoses and access the specific NICE guidelines. This way, you can ensure you enter the precise diagnosis.
- Times and dates. Virtually all documents you’ll be generating will include a time and a date. Use the times and dates tool for timestamping, dates of birth, appointment dates, and more, to keep your medical practice and electronic health records well-organized.
#4. Use Time-Saving Templates
One of the major benefits of using EHR software is taking advantage of time-saving templates.
Similarly to smart data entry tools, templates help you to automate data input by reusing repeated information.
You can use ready-made templates to:
- Quickly sort through documents based on the type of template used to generate the documents.
- Efficiently write texts and emails to your patients with custom templates.
- Take consultation notes faster than ever before.
- Minimize errors in data entry.
- Ensure that all documents include the key static information.
- Reduce staff workload and boost your medical practice’s efficiency.
- Save time on generating and organizing electronic health records and patient charts.
#5. Integrate Other Information Sources into the EHR Software
Organizing electronic health records with EHR software allows you to easily integrate other information sources into the system.
For example, you can link your EHR software to other systems used by the laboratories or other relevant departments you work with.
So, instead of having to wait for a physical copy of, for instance, an X-ray scan, you can access it directly from your EHR software as soon as another medical practitioner performs the scan.
As such, integration allows you to exchange information with your colleagues much quicker and more effectively.
#6. Customize Your EHR Software to Meet Your Needs
Each medical practice operates differently. So, to make the most out of organizing electronic health records, you want to customize your EHR software for your needs.
To increase your medical practice’s efficiency, it’s first important that you identify your requirements and needs. From there, you can see how you can tailor your EHR software to fit your medical practice.
For example, you can set up your EHR software to give you auto-fill suggestions when you’re entering patient symptoms. This way, you can reduce the time spent on entering data, and focus on your patients. As such, customizing your EHR software can also improve patient satisfaction.
#7. Enter Data During Consultations
Once you’ve created comprehensive patient records, automated data input, and customized your EHR software for your medical practice, there’s one more step left to organizing electronic health records - and that’s constantly updating your patient records.
To ensure your patient records stay up-to-date, it’s best to enter patient data during consultations. This way, you won’t forget to add any important information, which can help you to keep your electronic health records organized at all times.
That said, if you spend most of your consultation looking at your computer screen and typing, your patients may not feel comfortable.
So, here’s what you need to do to effectively enter patient data during consultations:
- Inform your patients. Acknowledge your patients and inform them of what kind of data you’re entering onto their electronic health records. This way, you can increase patient trust and make your patients feel more comfortable.
- Balance your focus. Of course, entering patient data is a responsible task. However, it’s important to stay aware of how much time you’re spending with your patients, and how much time you’re looking at the screen.
- Listen to your patients. Whenever your patients are sharing sensitive information, such as their symptoms, make sure to actively listen to them. If you start typing right away, your patient-doctor interaction may feel cold and impersonal.
- Keep eye contact. Whenever possible, make sure to face your patient and maintain eye contact. Not to mention, your hands should only be on your keyboard and mouse if you’re checking or entering information.
- Communicate with your patients. Instead of typing in silence, talk to your patients while entering data. Also, whenever you discuss test results or other medical data, make sure to tilt your computer screen and show it to your patients to keep them engaged.
At the Medesk medical information system, you can create any report templates that make it easier for the doctor to fill out the card and allow him to devote more time to the patient.Learn more >>
Looking for an EHR System to Organize Your Medical Records? Try Medesk
Medesk is a professional integrated medical practice management software that can significantly enhance your medical practice.
Besides storing and organizing electronic health records, Medesk comes packed with useful tools that can increase your medical practice’s efficiency and performance, including:
- Online booking tool that allows your patients to conveniently book appointments online.
- Medical billing tool that helps you effectively manage all of your payment-related procedures.
- A scheduling tool that allows you to keep track of your schedule, send automated appointment reminders, and more.
- Telemedicine tool that helps you to conduct consultations with patients regardless of their physical location.
- Integration tool that allows you to easily connect your EHR software to any other medical software that you use.
- Consultation note templates that will help you to optimize your note-taking.
And much more!
Want to try Medesk for your medical practice? Sign up for our free trial today!