In the world of private healthcare, patient record-keeping is at the heart of every clinic. The importance of managing patient records effectively cannot be overstated, it not only helps in maintaining an organised system but also plays a crucial role in enhancing patient care.
So, what constitutes good patient record-keeping? In this article, we’ll look at four key aspects that every healthcare provider should consider when managing patient records. Including accuracy, accessibility, security, and compliance.
1. Accuracy: The Foundation of Reliable Patient Records
Accuracy is the cornerstone of good patient record keeping. Inaccurate records can lead to misdiagnosis, incorrect treatment plans, and even legal issues. Therefore, ensuring that all information captured in a patient’s record is correct and up-to-date is essential.
For instance, details such as the patient’s medical history, allergies, current medications, and previous treatments should be accurately recorded. This information is vital for healthcare providers to make informed decisions about a patient’s care.
PPS comes fully loaded with a plethora of tools to make it a doddle to regulate patient data capture and ensure notes are kept up to date!
Key features:
Medical History
Using PPS’ built-in medical history form you can easily record vital patient data including existing health conditions, allergies and more. Each question is customisable to suit your clinic’s screening process and when used in the clinic, you can set review dates and alerts on critical information to make sure nothing falls under your radar!
Custom Forms
Take advantage of PPS’ custom forms feature to build custom assessment forms that can be used during treatment to regulate the type of data captured during your assessments. Using custom forms ensures all practitioners are asking the same questions and capturing that information in a format that is easy to refer back to, regulated data is also much easier to report on, meaning you will have easy access to patient statistics.
2. Accessibility: Ensuring Easy Access to Patient Information
Another vital aspect of good patient record-keeping is accessibility. Healthcare providers need unprohibited access to patients’ records for efficient service delivery. This can include GP referral letters, treatment history and even contact details. All of which create a client profile from which you can provide the best quality patient care.
Using practice management software like PPS is the first step towards building an accessible database from which you can run your practice. As an online solution, PPS is accessible from any location on any device, all you need is an internet connection!
Key features:
Attaching Documents
Upload external documents like GP referral letters to the client log to ensure all patient data is kept in one place.
Treatment Episodes
Help to form a full picture of a particular series of treatment sessions that can be categorised by department, diagnosis and more.
Client Details
Use the additional fields in the client profile window to record all third-party information including GP, Insurance and next of kin.
Options to explore:
If you’re not already familiar with PPS Express, you might want to give it a go! PPS Express brings a whole new meaning to the word ‘accessibility’, accessed from a web browser and optimised for use on smaller screens like smartphones and tablets, your data truly is at your fingertips at all times.
Sign up for your free 30-day trial of PPS Express here:
If you are already a PPS user, contact our sales team on sales@rushcliff.com to activate your free PPS Express trial.
3. Security: Safeguarding Patient Information
Patient records contain sensitive information that needs to be protected from unauthorised access and breaches. Therefore, security is a crucial aspect of managing patient records in private healthcare.
Securing your patient data comes in a few different shapes and forms, starting with how you choose to record your data. If you are using a patient management system and have digital records, you can easily employ additional security measures including regular data back-ups, robust firewalls and two-factor authentication.
You should also consider who has access to your data and how it is handled. All team members should be properly trained, only have access to the data that is necessary to complete their job and understand your procedures and policies.
PPS offers many features to support best practices when it comes to security.
Key features:
User Access Controls
Manage how your staff can interact with your patient data with user access controls, giving you the ability to choose which areas of the system the user has access to and what level of access they have, from read-only to the ability to modify or delete a record.
Data Audit
PPS comes with a built-in database audit, allowing you to easily review activity within your system, showing the details of every action taken in PPS alongside the user details, date and time stamps.
Free Online Tuition
Free online tuition: We offer unlimited online tuition, the perfect way to get your new team members up to speed quickly or a great opportunity to make sure all staff are confident in using new features or functionality in PPS.
Book your online tuition here:
4. Compliance: Adhering to Legal and Regulatory Requirements
Lastly, good patient record-keeping involves compliance with legal and regulatory requirements. These regulations are designed to protect patient’s privacy and ensure the quality of care.
In the UK, General Data Protection Regulations (GDPR) provide a clear point of reference for understanding exactly how personal data should be handled and should go hand in hand with your unique business policies and practices.
In order to ensure that you are meeting these requirements there are a few things you can do:
- Appoint a data protection officer – this does not have to be a new member of staff, but at the very least should be a member of the team that understands current regulations and guidelines and is able to ensure that your orgnaisation is adhering to any applicable regulations.
- Train all staff members – you handle personal data on a day-to-day basis and so it is important that all team members who have access to this data are up to date on best practices and your clinic policies
- Regular reviews – changes to guidelines, your team or even you general day-to-day business can all have an impact, so it’s important to regularly review your policies and procedures to ensure that they are still up to scratch!
To ease the load when it comes to compliance, PPS has some nifty built-in features that make it easy to follow GDPR.
Key features:
Data Audit
We’ve mentioned it here before, but the data audit enables you to track any action within PPS, giving you the opportunity to reflect on how your data is handled and adjust your policies or software settings accordingly.
GDPR Tools
On the client details screen you can tick a box to exclude a client from data processing on request (Article 21 – Right to object), you can also export their records (in accordance with Article 15 – Right to access) and you can completely wipe their data, even annonymising the data audit (in accordance with Article 17 – Right to erasure).
So when it comes to perfecting you patient record keeping process, break it down into the four key aspects above to ensure that you have everything under lock and key! Not only will adhering to these guidelines ensure that you are operating all above board, but it will also enhance the patients experience and streamline your workflows!
If you’d like anymore information on any of the PPS features mentioned in this acritcle, you’ll find links directly to our helpguides throughout the blog, or you can contact our support team via support@rushcliff.com if you’d like to have a chat.
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If you’re not already using PPS and you’d like to elevate your practice, you can start your free 30-day trial today!
