This documentation is placed in the patient’s chart and is available for the practitioner to review at the next visit. This provides for continuity of care in the event that another health professional in that office sees the patient as well as refreshes the same practitioner’s memory about the care he/she has provided for the patient.
Results from laboratory tests, X-rays, other diagnostic tests as well as a list of medications or treatments prescribed are also contained in the chart. In addition to this information, the chart will also contain any paperwork the patient completes, such as a family medical history, insurance information and consents for treatment, authorization to share information, and so on.
New Office New Chart
If the patient sees another health care provider, such as a specialist recommended by the primary care practitioner, a new chart is created and most often there is no integration of the information with the other physician's chart. If the patient is hospitalized, another chart is created. Each health professional creates a new chart or file for the patient and often has to reinvent the wheel to get a complete picture of the patient’s health history.
If the patient obtains medications from several different pharmacies, there is not a complete profile available at any of them. This sometimes results in medication errors from issues such as duplication of medications, or unknown medication interactions.
Oversight Not a Reality
Patients who have primary care providers who are willing and able to oversee the total care of a patient will have records sent from all sources of care each time they see another provider and review them. This is cumbersome, time consuming, and not reimbursable. In reality it does not happen often.
Most patients are not versed in medical terminology. Often they barely understand a diagnosis or treatment. Some things may seem totally insignificant and are forgotten, such as a visit to the Urgent Care for a virus or to the ER for a sprained ankle, and the information doesn’t get passed on to the primary care professional. A complication that could stem back to this illness or injury may never be connected.
Quality Improvement
In the interest of improving medical care, the establishment of electronic medical records (EMR) has become a hot issue and part of the health care reform debate. In order to create and maintain effective records, there has to be standardization procedures. Codes need to be applied to diagnoses and other information so that the records can be meshed.
The software in the physician’s office has to be able to communicate with the software the dentist uses, the eye doctor uses, the surgeon uses, the oncologist uses and the cardiologist uses or it is useless. It also has to be secure so that the patient’s information isn’t accidentally broadcast to those who have no need to know.
Health IT Growing Rapidly
This has opened up and broadened the scope of information technology in the health field. Health care IT (HIT) is one of the most rapidly growing career fields. HIT offers many diverse opportunities from medical records coding and management in a small medical office to a huge hospital or medical corporation.
Another opportunity involves data collection and management of diseases such as for tumor registries. Teaching physicians and other health care professionals how to use their system to record and retrieve data is a related option, as is maintenance of the hardware and software systems.
More information on this growing career opportunity is available from the American Health Informatics Management Association.
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