Patient records in a hospital start out as paper charts. Patients who stay in the hospital longer prior to being discharged develop lengthy records that should be converted to EHRs, or Electronic Health Records. It is best to do this process sooner than later, and the process can be started by the end of the third day of hospitalization. Start with chart abstractions.
Gleaning All the Right Information
If you were a patient and later requested your medical records, you would want to read what the records said. You would want to know what your doctors and healthcare team had to record while you spent time in the hospital. That said, you must abstract from your patients’ charts what you think the patients would want to read and hope to find. This includes medications prescribed, medical conditions treated, and treatment plans provided. These abstractions can be transferred directly into an EHR.
Making the Record Concise
A lot of patient information is written at length in files while the patient is at the hospital. While these records are important, you cannot enter everything that was recorded by nurses and doctors on the care team. Being concise as you transfer chart abstractions are key.
Using Software That Helps
EHR software often has the means of extracting key info from a patient’s paper file. Using the right software will make short work of the transcriptions. Researching these programs before your hospital adopts them saves time, money, and a lot of headaches later.
