As a caregiver, you know how medical records play a significant role in providing quality care to residents. Properly-maintained medical records help you communicate with healthcare providers, schedule appointments and manage medications. As a caregiver, one of your most important responsibilities is to ensure that medical records are well-maintained. Here we discuss some good medical record keeping practices to help you:
1. All the important details should be there:
Taking comprehensive notes is an important principle of good record keeping. When you are filling in medical reports, check whether the key pieces of information are included or not. Some of the important details that a medical record should have are:
- Relevant clinical findings
- Clinical decisions and action taken
- Medication prescribed, discontinued or dosage changed
- Who is making the record and when
2. Records must be clear, legible and accurate:
Incomprehensible and illegible writing leads to confusion which can negatively affect the care standard. While you are writing on paper MAR charts, take time to write legibly so that it is easily understood by your other colleagues. Medical records should also be:
- Accurate: Accuracy is especially important with treatments and medications. A misplaced decimal point can also lead to wrong dosage. For example, if a patient is supposed to take 1.0 milligrams of medication, but the record says to take 10 milligrams, this could lead to adverse drug events.
- Specific: The medical record has to explain how medicines are to be taken (orally, topically, or through other routes). It should be specific and there should be no room for ambiguity.
- Use only standard abbreviations: As a caregiver you may be tempted to use your own abbreviations to write fast. But what good is that medical record to other healthcare workers if they don’t understand the meaning of your abbreviations? Use only standard abbreviations that are commonly used and understood.
3. Changes must be recorded carefully:
Whenever a change is made to a medical record, it should be signed and dated by you. Additionally, when information is corrected, the original entry should be made illegible by drawing a single line through it. This helps to ensure that everyone who has access to the documents has a complete and accurate picture of the patient’s medical history.
4. It should have the medication list:
It is important for every patient in care homes to have a medical binder. This binder should include a list of all past and current medications, as well as any medications or supplements that are taken on a regular basis. For each medication, it is important to document the dosage, the start date, drug name and side effects that have been experienced.
5. Organise medical records
Many care homes are using top EMR systems to digitise the medical records of their residents. Since the software can document a resident’s health information over an extended period, it helps doctors, nurses, caregivers and other medical professionals to make better-informed treatment decisions. If your care home uses common EMR systems, ask your supervisor to make sure you get adequate training.
In the UK, many care homes are using electronic MAR to streamline medication management. Here are some benefits of using eMAR
- Easy access to residents’ medication information: With just a few clicks, you can have access to entire information about residents’ medication. You don’t have to go through piles of paper to access information. You and your supervisor can access information on a real-time basis without being physically present in one place. This allows instant collaboration.
- Alert feature ensures that no dose is missed: You can set alerts on the eMAR so that you don’t inadvertently forget to administer medication to any resident.
- Increased accountability: Paper-based MAR charts leave room for a lot of human errors and confusion. In eMAR, changes made by different caregivers are recorded and there is no need for finger-pointing.
- Reduced paperwork: Monthly reports are an important part of compliance. But going through each paper manually to prepare a report can be time-consuming. With eMAR, you can prepare detailed monthly, quarterly and yearly reports without much hassle.
To know more benefits of using eMAR, here’s a useful read.