What Are Medical Documents? How They Enhance Patient Care

Healthcare providers consistently strive to deliver exceptional patient care amidst the complexities and dynamic nature of the healthcare industry.

One key aspect of providing quality healthcare revolves around access to patient information, such as medical history and past diagnoses. Medical documents serve as the bedrock for patient care, allowing healthcare professionals to make informed decisions and deliver effective treatments.

To ensure optimal care, it is crucial for providers to implement a well-managed system for handling medical documents. As the volume of this data continues to increase, investing in clinical documentation software becomes a requirement. By leveraging such technology, providers can enhance patient outcomes and streamline healthcare processes.

The importance of medical records or clinical documentation in the healthcare industry cannot be emphasized enough. In this article, we explore the different types of medical documents, their significance, and the benefits and challenges that healthcare providers face in managing and preserving them.

Purpose of medical documents in medicine

Medical documents serve a crucial purpose in the field of medicine. They play a fundamental role in documenting and organizing patient information, facilitating effective communication and collaboration among healthcare providers. Here are some key purposes of medical documents:

• Quality care. Clinical documentation makes sure patients receive the proper treatment by providing medical professionals with the information to make good care decisions. Access to the patient's diagnosis, treatment plan, and medical history allows healthcare workers to provide quality care through clear communication among all members involved.
• Legal and regulatory compliance. In the case of legal proceedings, medical documents can serve as evidence. Accurate documentation must also comply with the Health Insurance Portability and Accountability Act (HIPAA) and General Data Protection Regulation (GDPR).
• Hospital funding. Medical documents are service documents that have implications for hospital funding. Each issue is recorded and translated into a cost for the hospital system to ensure they’re appropriately compensated for their services.

Types of medical documents

Understanding different types of medical documents used to provide effective patient care is essential.  Three kinds of medical records are commonly used by patients and doctors:

• Personal health records (PHR) refer to personal and family medical history, immunization records, medication, and financial data. The patient often maintains this info.

• Electronic health records (EHR) contain a patient's medical history from multiple healthcare providers and may include lab results and medication lists. These records pass on information to other healthcare providers and organizations.
• Electronic medical records (EMR) are digital versions of paper documents created and maintained by healthcare providers for easy access and storage. 

What should medical documentation include? 

The components of a medical document vary depending on the document type and the healthcare establishment, but here’s a list that works as a jumping-off point.

• Identification information includes the patient's name, date of birth, age, marital status, and social security number. 
• Medical history comprises information about the patient's allergies, hereditary conditions or diseases and prior diagnoses.
• Treatment history includes a record of all vaccinations, medical treatments, procedures, and operations.
• Medication information tells healthcare workers the medicines a patient takes or has taken in the past. It can include data on the dosage of over-the-counter (OTC) drugs, herbal remedies, or recreational substances. This information is crucial in enabling doctors to prevent harmful drug interactions and create treatment plans. 
• Medical directives are legal documents such as do-not-resuscitate (DNR) orders and living wills encompassing the patient's wishes for medical care. They can be accessed in a case when a patient cannot communicate.
• Lab results consist of data from radiology tests such as X-rays and other imaging tests. 
• Consent forms document the patient's understanding of their medical condition, the recommended treatment plan, and any potential risks associated with treatment.
• Progress notes track changes and updates in a patient's condition, like vital signs or food and water intake. They help healthcare providers monitor patients' progress and adjust treatment plans as required.
• Financial information includes the patient's insurance information, policy number, insurance payer's name, and contact information. This information is crucial for smooth billing and reimbursement procedures.

Typical medical documents

While the following types of medical documents are the most common, variations might come up depending on the healthcare establishment.

• A patient information leaflet (PIL)  is a handout that comes with any medicine purchased at a pharmacy. It contains vital information about the medication purchased, such as its conditions, side effects, dosage, and storage. 
• Medical tests could be blood tests, urine tests, and heart tests, along with many others in this category. 
• Mental status examinations assess a patient's cognitive abilities. 
• Consent forms are documents that indicate a patient’s permission for medical procedures, such as surgery or experimental treatments. 
• Operative reports detail the procedures and findings of surgical operations. 
• Medical history records summarize a patient's medical history and include past notes from healthcare specialists. 
• A discharge summary is prepared when a patient leaves care. It typically includes information on the reason for admission, test results, and medical advice for the patient after discharge. 
• Insurance forms are necessary for patients to receive medical coverage from their insurance provider.
• Referral letters are usually for specialized care. They contain the patient's medical history and the reason for the referral.

How to access medical documents

To access medical records, individuals must first identify which healthcare provider has the medical information required. They can then access medical records through the online patient portal at most healthcare establishments. If under 18, a parent or guardian may need to request medical records, and written permission must be provided.

Given the extensive length of medical documents, patients have to be specific about the requested information, whether it involves medical records, test results, or treatment summaries. Understanding which record is required significantly impacts the efficiency and effectiveness of accessing and reviewing the necessary information. 

Patients must clearly indicate the preferred method of receiving the information. It may take up to 10 days to process the request after filling out an authorization form. If the patient needs their records immediately for treatment or an appointment, physicians can request records by fax at no cost to the patient.

Types of medical document requests

Patients or their authorized representatives can make several types of medical records requests

• Personal copy request is a request the patient makes. 
• Continuity of care request is a request a healthcare provider makes in order to continue patient care.
• Insurance or disability request is a request an insurance company or government agency makes to process a claim or determine eligibility for disability benefits.
• Legal request is a request a lawyer or court makes concerning a case.
• Research request is a request researcher makes to conduct a study or research project.

It's important to note that different requests may have different associated requirements or fees.

How to correct medical documents

If a patient suspects that the information in their medical document is incorrect, they have the right to request a change or amendment to rectify any inaccuracies. Healthcare providers are legally obligated to respond and work on these kinds of requests.

If the healthcare provider is responsible for creating the information in question, they must make the necessary amendments to address any inaccuracies or incomplete information. But sometimes, the provider may disagree with the request for a change. In cases like that, the patient can voice their disagreement by submitting a statement expressing their concerns. The provider should also add this statement to the record.

Patients have to be proactive and advocate for the accuracy of their medical documents, as it plays a significant role in ensuring they receive the proper treatment. 

Future of medical documents

The long-term research value of historical medical records in healthcare analytics may not be immediately obvious to those outside the medical and health information management fields. People may wonder why it's necessary to save records that can't be accessed by the general public for many years and require expensive data storage and secure access. 

However, federal privacy laws such as HIPAA require that records with personal health information be closed for research for fifty years after the individual's death. Transitioning from manual storage methods to more efficient solutions to address these challenges is crucial. 

Many individuals and organizations are now opting for clinical documentation software to securely store, manage, and model data from medical records, enabling easier access and facilitating future research endeavors.

Benefits of clinical documentation

Clinical documentation plays a vital role in healthcare operations, providing numerous benefits for healthcare professionals and patients alike.

• Improved efficiency. Electronic medical document management systems can iron out workflows and reduce the time required to manage patient records. This can improve overall efficiency and productivity within a medical institution.
• Enhanced accuracy. Using software reduces the likelihood of errors found in manual record keeping. 
• Improved security. Electronic medical document management systems provide better patient data security with access controls, audit trails, and encryption, all of which safeguard sensitive patient data. 
• Cost savings. Digital storage eliminates the need for physical storage space and associated costs such as rent, utilities, and maintenance. It can also reduce the need for printing and paper-based document management systems.
• Better collaboration. Electronic systems can facilitate collaboration between different healthcare providers and departments, improving communication and coordination of care.
• Increased accessibility. These systems can provide easy and secure access to patient records from anywhere with an internet connection. 

Challenges of clinical documentation

Clinical documentation is essential to healthcare operations. However, healthcare professionals often face several challenges while implementing it. 

• Time constraints. Healthcare providers are often busy attending to patients, which leaves limited time for documentation, leading to incomplete entries leading to inaccuracies.
• Inefficient tools. Poor design, complex interfaces, and counterintuitive workflows can hamper proper documentation processes.
• Lack of standardization. Inconsistent documentation practices across healthcare settings create data exchange and interoperability obstacles. 
• Limited training. Inadequate training contributes to documentation challenges for healthcare professionals.

Best clinical documentation software

In today's world, the need for digital record-keeping is increasing. Luckily, you have your choice of tech that will make sure you keep up with requirements and ensure accuracy, efficiency, and transparency in managing documents. 

For medical establishments, a good clinical documentation software tool can significantly improve medical records management and make certain that patient data is stored securely. 

For software to be included in this category, it needs to:

• Have an intuitive, easy-to-use interface.
• Allow for customization of templates and forms to fit specific needs.
• Seamlessly integrate with other healthcare management software.
• Comply with industry standards and regulations, such as HIPAA, to ensure the security and privacy of data. 
• Simplify sharing of patient information and updates within departments.
• Be accessible from multiple devices and locations to find patient information remotely.
• Have robust reporting capabilities to analyze and monitor documentation quality and compliance.
• Provide strong technical support and training resources

*Below are the top 5 leading clinical documentation software solutions from G2’s Spring 2023 Grid® Report. Some reviews may be edited for clarity.

1. Pabau

Pabau is a comprehensive clinic management software tool designed to help clinics and med spas simplify operations and provide top-notch patient care. With over 2,000 clinics worldwide using it, Pabau is committed to helping businesses automate tasks and improve the patient experience. The software offers many features, including electronic medical records, calendars, payment systems, and online bookings. 

What users like best:

"Since implementing Pabau in my clinic, I've been able to streamline my business operations and save valuable time. Now, I can view my patient's journey, manage marketing campaigns, and track new leads all in one place, which was a real challenge before."

- Pabau Review, Craig H.

What users dislike:

"There are a few areas where there's room for improvement. For instance, some of the forms can be confusing at first. The app interface could be better, especially when using it on an iPad with a keyboard, as the orientation doesn't change when using certain parts of the app. Lastly, it would be great if Pabau provided more information about the client portal to clients through email or other means.”

- Pabau Review, Siobhan A.

2. ECP

ECP is a web-based software solution that's tailored to the unique needs of assisted living facilities. With an integrated electronic medication administration record (eMAR) and EHR, ECP plays the go-between for the pharmacy and home with an automated medication check-in process. It also provides assessments, care charting, alerts, task lists, and reports to improve care quality and efficiency. 

What users like best:

"The platform is user-friendly and intuitive, making it simple to navigate and find the information you need. Additionally, customer support is highly responsive and readily available to assist you with any issues.”

- ECP Review, Tom K.

What users dislike:

"The cost of this software is an issue, as the charges to the pharmacy are unreasonably high. Additionally, the installation fee seems unnecessary and adds to the overall expense. On top of that, the software does not interface well, and it's difficult to determine whether it's running properly.”

- ECP Review, Jacob R.

3. Foothold

Foothold provides electronic documentation software for I/DD and behavioral health service providers. The comprehensive platform includes case management, client tracking, and an EHR that can streamline your workflow. The platform is fully HIPAA-compliant and ensures the highest level of data security. 

What users like best:

"This system is easy to use. It provides us with tools that help the staff document services more efficiently and accurately. Additionally, a configurable solution for each program is available, including connecting all the specialists involved in the care of their clients, including laboratories, pharmacies and collaborators.”

- Foothold Review, Steven J.

What users dislike:

"Finding reports I've created is challenging. It takes so many menus to find them I've had to recreate some I've lost. The reporting tool is just messy in general. Additionally, sometimes it is hard to navigate out of a sub-screen back to a previous screen without going back through a screen you've just filled in.

- Foothold Review, Laura M.

4. Kareo, a Tebra Company

Kareo, a Tebra Company, is the only cloud-based technology platform exclusively designed for independent medical practices. With Kareo, you can easily capture and manage all patient data, verify insurance benefits electronically, and set up patient alerts to optimize efficiency. You can also get instant access to every patient's financial history and view detailed ledgers filtered by case, date range, provider, and more. 

What users like best:

"The ability to access client charts on both phones and desktops is an excellent feature. Additionally, the ability to create quick drop-in notes is a time-saving tool. The app's functionality to email or text clients directly adds convenient communication. The inclusion of a history list for easy reference and re-accessing client information is also highly beneficial. Furthermore, the app's ability to run reports and surveys provides valuable insights."

- Kareo, a Tebra Company Review, Deidra W.

What users dislike:

"Patient paperwork should auto-populate in the chart. When patients complete family history, previous meds, personal medical history, demographics, and other forms, entering all that into the chart is cumbersome and time-consuming."

- Kareo, a Tebra Company Review, Naomi M.

5. Axxess Home Health

Axxess Home Health is the leading technology innovator for healthcare at home. A scalable electronic medical records software and mobile app, it’s used by over 8,000 organizations worldwide. This cloud-based, HIPAA-compliant system is securely accessible on all devices, including iOS and Android. 

What users like best:

"Ease of use, scheduling is effortless, and when changes need to be made, you can do them instantly.”

- Axxess Home Health Review, Annette T.

What users dislike:

"Poor customer support and long wait times for ticket resolution are common issues that they should work to address."

-Axxess Home Health Review, Mario M.

Documenting like a boss

Proper documentation supports patient safety, facilitates communication, and enhances decision-making. By maintaining comprehensive and accurate medical records, healthcare providers ensure optimal patient care while minimizing legal risks. 

Investing in good clinical documentation software helps healthcare providers improve efficiency, reduce errors, and demonstrate compliance with legal and regulatory requirements. Maintaining medical records is ultimately critical to achieving the best patient outcomes and promoting trust in the healthcare system.

Are you looking for a more structured approach to storing, managing, and collaborating on electronic information? Look no further than the best document management software.