-- Every patient's record must contain information about any allergies the patient might have. As every MA and nurse knows, common medicines such as the antibiotics penicillin, cephalosporins, sulfonamides, or vancomyc can cause anaphylactic shock. Allergic reactions to medicines may range from the mild (a rash) to the severe (death).
Medicinal allergies are not the only cause for concern, however. The record should state clearly whether the patient has a particular food allergy or other similar problem which may affect a diagnosis or advice given over the phone. Too often, a patient must be asked if she has an allergy every time she comes in because the record does not reflect. If she were to be incapacitated and unable to respond, the results could be catastrophic if knowledge of an allergy is not at the fingertips of the medical professional.
-- The medical record should contain a comprehensive account of the patient's prior medical history, including any surgeries she may have had and any chronic conditions she may still have. Having this information easily on hand at the time that care is being provided will reduce the chances of prescribing the wrong medications or making the wrong diagnosis.
-- One of the biggest logistical problems for medical professionals is being able to coordinate care between themselves and other professionals who may also be treating the patient. A physician should always have access to information about the patient's care from skilled nursing facilities, home care agencies, hospitals, and other doctors so that the coordination among these parties can be seamless.
Today's EMR systems really help different health care professionals to know what each other is doing so that the patient is getting the best and safest care possible.
The days are long gone when the family doctor knew everything about their patients and could operate just fine by maintaining paper files. Today's busy medical offices put their patients' well-being in danger if they insist on keeping records in an antiquated manner. All patient records, from allergies to long-term medical history, to information from other providers, should be easily accessible and clearly understandable.
Author: Art Gib
About the author:
If your medical office wants to increase record keeping efficiency by usingEMR systems, contact the experts at Prime Clinical Systems (http://www.primeclinical.com). Art Gib is a freelance writer.
Article source: Free Management Articles.
