In a way, patient charts are the crux of the medical industry. They substantially increase the likelihood of positive patient outcomes and give medical professionals the general patient profiles they need to develop meaningful treatment plans. Virtually every reputable medical practitioner uses them to guide their clinical decision-making. Read on to learn why patient charts matter and how you can use them.
A patient medical chart, commonly referred to as just a patient chart, is a complete and total record of a patient’s clinical data and medical history. Typically, patient charts include vitals, medications, treatment plans, allergies, immunizations, test results, patient demographics, diagnoses, progress notes and reports. All information in patient charts comes from nurses, lab technicians, physicians and other practitioners involved in the patient’s care.
Proper patient care involves addressing a patient’s symptoms in the context of the big picture. Patient charts are that big picture. The comprehensive patient data they provide gives you all the information you need to make proper diagnoses, prescribe appropriate medications, order appropriate bloodwork and set up robust treatment plans. Without patient charts, even highly experienced doctors can misdiagnose patients or set up treatment plans that yield no results.
Additionally, medical billers and coders rely on the information in patients’ charts to generate medical claims. Claims are then submitted to payers like insurance companies in order for practices to collect the money they are owed for services rendered. Without a comprehensive medical chart, it is virtually impossible for medical billers to effectively do their job. [Looking to improve how you track patient charts? Read more on how to choose an EMR system for your practice.]
A typical patient chart includes the following information:
Patient charts include demographics, medications, allergies, family and medical histories, immunizations, surgical history, lifestyle details, developmental history, and pregnancies.
During each patient encounter, practitioners should add the following to the patient’s chart:
During a patient encounter, you should add the patient’s symptoms, diagnoses, physical exam notes, treatment plans, lab and testing info and results, prescription, and treatment progress to their chart.
Patient charts vary in appearance based on the EHR system (also known as an EMR system) your practice uses. Below is an example of what patient charts look like in athenahealth’s EMR system. For a closer look, read our review of athenahealth’s medical software, which includes its EMR system, athenaClinicals.
Digital charts like these can usually be customized by healthcare providers to suit their preferences. Most EMR systems also offer the ability to create templates and favorites lists, making it easier to navigate to frequently used tools, diagnoses, prescriptions and lab orders. Healthcare providers are also able to send these charts securely to other healthcare providers when needed, cluing in a patient’s other care teams on relevant information your practice might have uncovered during their last visit.
On the other hand, a paper chart might look like this:
Medical professionals highly encourage EMR use over paper charts. The Centers for Medicare & Medicaid Studies (CMS) previously offered incentives to encourage adoption; however, organizations that fail to meaningfully implement medical software now face penalties to Medicare and Medicaid reimbursements. To learn more about why EMR software is superior to conventional paper charts and why regulators are pushing for mass adoption, visit our reviews of the best EMR software providers.
Patients can access their own charts via the patient portal, as can any nurses, lab technicians, physicians and other medical personnel involved in their care. However, the chart ultimately belongs to the patient even if it’s stored in your EMR, as patient charts contain sensitive patient information. Patients can thus demand their medical records from you at any time or grant access to anyone they desire. They can also demand that you rectify any inaccuracies.
Technically, a patient chart belongs to the patient.
By definition, EMRs are digitized versions of traditional patient medical charts. These digitized versions make the information in a patient chart significantly easier for all your medical staff to quickly access. Instead of rifling through paper records, you can just load your EMR on your computer or phone, open your medical software platform and then access your patient charts.
EMR patient charts are also better for comprehensive care, as everyone involved in the patient’s care can add their encounter notes to the same digital document. Then, when the next medical professional encounters the patient, they’ll have all the information they need, ordered chronologically, to properly care for the patient. The result is a more thorough, streamlined care experience for patients and providers alike.
Technically, “EMR” describes solely digital patient charts, whereas “EHR” – with which the term “EMR” is often used interchangeably – describes EMR and additional tools for improving patient care and communicating with other healthcare providers. These tools include electronic prescribing and lab ordering, as well as telehealth technology and interoperability measures for communications with specialists and physicians outside your practice.
In short, EMR includes solely patient charts, and EHR makes EMR easier for practices to work with. To learn more, read the Business News Daily guide to EMR vs. EHR.