What are Medical Records Systems?

Medical records systems are hard copy or electronic systems that are used to organize and catalog information regarding treatments, general health conditions, and other data that is relevant to patients. Today, many doctors’ offices, hospitals, and other types of short- and long-term treatment facilities make use of software programs to create a customized medical records system. Here are some examples of what type of data is kept in the systems and how they are used.

Central to all types of medical records systems is the patient information that is contained in the catalogued data. It includes such basic information as the name, gender, and age of the patient. Contact information for next of kin or other persons authorized to receive information about the patient are also listed within the records. Notes on any allergies are also documented. If the patient has some type of insurance or some kind of health care discount plan, relevant details are also kept in the patient file.

Along with the basic patient data, medical records systems are also capable of storing years of information about doctor’s visits, hospital stays, surgical procedures, and medication prescribed on a short- or long-term basis. Most systems include fields where physicians, nurses and other authorized medical personnel can enter notes relevant to each event where medical care was extended to the patient.

Medical records systems sometimes also serve as a means of documenting communications with the patient or the insurance provider. The system can capture the dates that claims were prepared and submitted to the provider, the responses to the claims, and any payments received from the insurance company or directly from the patient. This makes it possible to generate invoices to the patient that keep him or her apprised of the current status of the account.

With the advent of electronic medical records systems, many procedures that used to take hours can now be accomplished in much less time. For example, the electronic medical records can be searched using keywords, making it possible to quickly review patient histories going back a number of years without wading through large amounts of printed documents. In addition to retrieving information quickly for the purpose of providing medical services to the patient, computerized medical records also make it easy to compile statistics on the number of patients treated for a given malady or the types of medications most often issued by a given physician. Data of this type can be very helpful when evaluating the scope of a practice and the general quality of care offered by a physician.

As a health information management tool, the value of electronic health records cannot be underestimated. Data that would have to be stored at a remote storage facility can easily be entered into medical records systems and stored on a hard drive as well as on CDs for easy retrieval. This helps to keep printed documents to a minimum and frees up space for other purposes.

In addition to residing on hard drives or local servers, medical records systems can also be housed on a remote server and other remote data storage solutions. This benefit is especially helpful in situations where there is a desire to keep backup copies of data available. Should the doctor’s office or hospital experience damage due to a natural disaster, all the patient data is still preserved and can be accessed using the proper authorization codes.