Paper Medical Record System Presently

Paper medical record system presently signifies an enormous disintegration of patient health record. Not only it is hard to manage tons of paper work, it increases the cost of the health care system due to information disintegration leading to the adverse effect on the present and future patient health care. Accessibility of applicable data presents unbelievable perspectives such as it decrease clinical errors, and therefore it amplifies the quality of health care provider. It also support health care professionals in their responsibilities and investigate work.

How the Paper Medical Record was created

Accurate medical records are essential to patient care in any health care setting. One in correct digit in a patient's social security number causes reimbursement problems. An incorrect address or telephone number or misspelling of a name makes it difficult to contact patients about test results and prescription refills. Medical errors are even more disastrous and can cause serious medical problems for patients. Patient files are critical to the facility's smooth functioning and are vital when referring the patient to outside specialists with whom the facility may need to coordinate with whom the primary care provider may need to coordinate care.

The patient's medical chart is prepared on or before the day of the patient's first visit in the medical facility. Paper medical records require the assembly of appropriate file folders, divider pages labeled with identifying tabs, and a number of essential forms to be completed by the patient. Included forms provide demographic information, social and family medical history, previous surgeries, HIPAA guidelines, and release of information details (Engelbrecht, 2005). Often, paper chart include adhesive twin prong fasteners to ensure that sheets of paper are securely held within the chart.

Paper medical records are stored in any secondary or primary locations that are normally in the healthcare organization. Records of full medical operations are stored in primary storage facility, and are filed numerically in an attempt to realize efficiency. The filing system of an organization is usually numerical, and is based on terminal digits of the patient's HRN (Health Record Number). An up-to-date copy of the Paper-based medical records register should be kept in the file at all times. This may be the system used most of the time to locate medical records but it also provides a system to search when the power fail. Ideally, two-colored coded number of stickers are placed on the protruding right hand side back cover, of the medical record cover. These numbers normally match the last numbers on the HRN on the register. The digits that are colored, and in the case where they are misplaced, then it will show that the charts are misfiled. Ideally, file location can be determined from the color grouping through the use of the last digits of HRN that is written above the colored stickers.