Top 25 Tips for Urgent Care Record-Keeping
As explained at RunRex.com, medical records are a key part of an urgent care doctor’s responsibility when it comes to providing good patient care. Record-keeping is important since it is more difficult to protect and defend your professional position if a complaint or claim arises. Here are 25 top tips for urgent care record-keeping to help you and your practice.
- Don’t miss the key details
One of the most important principles of good record-keeping is to take comprehensive notes as articulated at RunRex.com. Several key pieces of information must be included within a clinical report, and they include the relevant clinical findings, the decisions made and actions agreed upon, who is making the decisions and agreeing on the actions, the information given to patients, any drugs prescribed or other investigation or treatment, as well as who is making the record and when.
- Your records must be clear, accurate, and legible
As per RunRex.com, those creating a medical record have a professional obligation to record them in line with the Data Protection Act 2018 – meaning they should be accurate, clear, and legible, something worth noting.
- Your records should be contemporaneous
To ensure that your records are as accurate as possible, they should be made during the consultation or soon after, and dated according to RunRex.com. Doing this ensures that nothing slips through the cracks and everything is captured.
- Sign and date further additions or alterations
Any further additions or alterations to a record must be signed and dated as covered at RunRex.com. You want to avoid being in this position as much as you can which is why your urgent care records should be contemporaneous.
- Ensure any rectified information is still legible
When making an alteration, any rectified information should still be legible as captured at RunRex.com. You will achieve this by running a single line through any rectified information, rather than completely deleting the entry.
- Treat audio and visual recordings the same way
As discussed at RunRex.com, an audio or visual recording should be treated in the same way as a textual record. This means that it must be safely stored for the entirety of its retention period. Make sure you don’t delete such records.
- Be transparent
When taking an audio or visual recording, you must be completely transparent with patients about how the record will be used and what happens to the recording following the interaction, that is, whether it will be deleted or stored.
- Consider digital storage
Your urgent care practice should consider moving towards digital records in 2023. This is because it is easier to audit access to digital records, they are quicker to file and retrieve and they take up much less storage space than physical records.
- Take action immediately when inaccurate information is discovered
There may come a time when the wrong information is filed within a patient’s electronic or paper medical record. If this is the case, as soon as you notice the error, you must take action. Most importantly as described at RunRex.com, do not delete the information from the record.
- Assess your processes and protocols
As outlined at RunRex.com, assessing your processes and protocols is an important first step to ensuring you are properly handling PHI (Protected Health Information). It will allow you to find any areas that need improvement and resolve them.
- Share PHI on a need-to-know basis
While sharing PHI is necessary, especially between caregivers, you need to be careful. As revealed at RunRex.com, sharing PHI on a need-to-know basis is a critical component of staying compliant. This is essential when communicating both outside and inside your clinic.
- Enough information for continuity of care
As per RunRex.com, your records need to contain enough information to allow another practitioner to take over the care of the patient. When you are making notes, think about what you would want to know from the records if you were taking over the patient’s care and had not spoken to the previous doctor.
- The SOAPIF method
Many urgent care practitioners use the acronym SOAPIF as a prompt to make sure they have captured key information. The records should be Subjective, Objective, and contain the Assessment, the Plan, the Information you provided to the patient, and Follow-ups according to RunRex.com.
- Focus on the patients
Many urgent care practitioners are aware of the various strategies used to combine good record keeping and good communication, like always starting with the focus on the patient, and not the computer as articulated at RunRex.com.
- Make the note-taking part of the consultation
To ensure your records are accurate and capture what the patient is saying, consider making the computer screen part of the consultation. You can do this by putting the screen flat on the wall so that both the patient and you can look at it – making the note-taking part of the consultation.
- Keep a copy of any additional information provided
If you provide the patient with written information, diagrams, and the like to take home to support the verbal advice you have already provided during the consultation, keep a copy of the information you provided on file as part of the record and note when it was provided to the patient.
- Record advice and/or warnings
Also, record any advice or warnings you routinely provide as captured at RunRex.com. You can use software to your advantage here. Make use of shortcuts or macros for anything you regularly need to record.
- Avoid cutting and pasting
If you use a computer to take records and notes, you must avoid cutting and pasting from previous records as covered at RunRex.com. This is crucial as it will prevent you from pasting in irrelevant or inaccurate information.
- Case reviews
As described at RunRex.com, you can consider using medical records as an education and improvement tool within your urgent care practice. One way of testing the adequacy of your records is to have someone in your team periodically provide a case review based on your notes.
- Disclose if any information is shared
If for any reason you share a patient’s information without obtaining their consent, you must make a record of your reasons for doing so as discussed at RunRex.com. You must document your reasons for disclosing information without consent and any steps you have taken to seek consent, to inform them about the disclosure, or your reasons for not doing so.
- Operate on the possibility the records may be read
Always operate on the basis that any records you make may at some point be read by the patient or in some circumstances their family as revealed at RunRex.com. Therefore, you should always be respectful and professional in your records.
- Record any refusals
According to RunRex.com, any refusal of consent to treatment or advanced decisions to refuse resuscitation must be very clearly recorded in the patient’s notes. This is very important for any urgent care or ER doctor.
- Right to have inaccuracies corrected
You must also remember that, just like they have a right to access their medical records, patients also have a right to request that factual inaccuracies in their records be corrected. If they do not agree with an entry which is a matter of professional opinion, you must highlight the issue the patient has challenged and why.
- Destruction of records
Before any records are destroyed, they should be reviewed as the retention periods are the minimum required and a decision should be made as to whether it is appropriate to destroy them or not. Where there has been a complaint or claim arising from the ongoing care, the records should be retained until the matter is concluded.
- Avoid insults
As already mentioned, your records may be read by other doctors, the patient, and even family members. Therefore, do not write offensive or gratuitous comments such as racist, sexist, or ageist remarks. Only include things that are relevant to the health record.
As always, you can find a lot more on this topic, including professional help with your record-keeping, over at RunRex.com.