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Many medical professionals worry about what could only be a doctor’s or nurse’s worst nightmare: mismanaged medical records. These records could include anything from the wrong diagnosis to treatment to medication. Unfortunately, some errors made in medical documentation can be severe and even fatal.

Although many doctors and nurses are aware of the perils of medical record errors, they also know that the issue can be challenging to prevent. Unfortunately, because of oversight and lack of awareness, improper training of staff, and possibly ignoring the most routine aspects of ensuring that accurate medical records are maintained, some medical professionals miss the obvious warning signs of medical record mismanagement.

A medical record contains a wealth of information that could save a patient’s life. It’s also a critical factor in legal issues that injury lawyers have to deal with. Still, carelessness in data entry can result in a series of medical errors that could be avoided. When such errors are ignored, they may prove to be disastrous. Here are the steps on how to prevent medical record mismanagement:

Train Your Staff On Proper Medical Documentation And Management

With the increase of health-related issues that have been identified in recent times, more medical establishments have realized the necessity of developing a system for proper medical record management.

You can find several organizations that offer training in medical record management. The only important thing is to ensure that the training you receive is from an authentic and highly reputed organization and will help you and your staff to perform your roles well. Such training programs usually last for about six weeks, and you have to be extremely careful about checking whether or not all the information and protocols you’ve learned have been appropriately implemented into your hospital or clinic.

Store Digital Copies Of Medical Records

You’ll have a better idea of your patient’s needs when you have an electronic health file. You can have centralized patients’ records about their current health status, drug prescriptions, and any updated information about them. It’s also easier for other doctors and nurses to look into a particular person’s medical records when they’re in electronic form.

There are software programs that can help you with your record-keeping tasks by storing your medical records in an organized manner. You can download any of them over the Internet and install one on your computer or laptop. This is one of the simplest ways to avoid medical record mismanagement. Such programs have different features, so compare them carefully in order to choose the most suitable software for your health establishment.

Have A Checklist For Documentation And Storage

One of the tips on medical record management you have to follow is to prepare a checklist for proper documentation and storage. You have to identify all the areas where you store your patients’ paper-based records within your medical office, clinic, or hospital. You have to ensure that those places are adequately equipped with the necessary furniture and supplies for storage. You also need to provide separate space for the records and other pertinent documents for different departments to keep their respective records organized.

Update Your Medical Records Management Software

Another thing you need to do is to update your medical records management system regularly. You have to be aware that from time to time there’ll be updates for whatever program or software you’re using for electronic medical records. You have to check for them so you can maintain proper documentation for your patients. It’s also essential to look into your patients’ records often to monitor and input any changes or new illnesses they may have developed.

Invest In New Technology Preventing Duplicate Medical Records

Many health care organizations invest in touchless biometric patient identity management solutions to prevent duplicate records of the patients. These systems are also considered one of the best forms of patient data storage available because they require minimal clearance procedures to access.

Since the biometric data needed for the system is stored electronically, validating a person’s fingerprint requires only a few minutes instead of several hours or even days of phone calls going back and forth between doctors and other staff members. This means that medical professionals can quickly determine whether or not a person’s fingerprint is authentic, which is vital in many situations. In addition, biometric patient records can be matched quickly using online services, which can help medical offices keep up with various legal requirements.

Takeaway

Medical errors have accounted for some of the death tolls from diseases throughout the history of medicine. One way to prevent them from occurring is by addressing the issue of medical record mismanagement. This should always be high on the list of priorities for those involved in the medical field due to the need for patient information confidentiality and maintenance of medical records for safety and regulatory purposes.

Medical translation plays a crucial role in bridging the communication gaps between medical providers and their multilingual clients. According to Joint Commission Standards and Healthcare Compliance Law, hospitals need to find translators that can help convey important and personal health information (PHI) to Limited English Proficient speakers. However, it is crucial to keep this confidential info private and prevent disclosures to unauthorized persons. These standards are included in the Health Insurance Portability and Accountability Act (HIPAA).

In consideration of these two policies, hospitals need to assure that their medical translators value the privacy and clarity of information they translate. It is important the language service provider is HIPAA compliant and has legal certifications to perform their job.

How does HIPAA compliance work with medical translation services?

For the security of patients’ PHI, it is crucial for medical translation services to undergo thorough quality assurance and high-security measures. From the safe and secure file transfers to the actual translation process and turnaround of the project, everything must be highly confidential. 

For example, the translators cannot request or send files via email as this would violate the HIPAA regulations. Instead, they can use encrypted file-sharing platforms that can securely transfer files. This is because emails are prone to cyberhacking, and any malicious entities that could breach these data could use the patient’s PHI for identity fraud. 

When this happens, the medical providers and translators need to inform all the affected patients about the situation. In the end, your reputation will be compromised as your patients lose their trust in your hospital.

Thus, the hospitals need to ensure that the medical translation services they will get are HIPAA compliant. As such, they should have an effective project management portal that will secure the document uploads and downloads. Their network of professional translators must also have adequate training regarding the security assurance processes.

Here are the things that hospitals must do before hiring medical translators:

• Assess the privacy risk of the company that provides medical translation services.
• Provide proper guidelines regarding information access in the vendor-client agreement.
• Set terms and conditions to ensure that the medical translator will meet the regulatory compliance.
• Outline and sign contracts to outline the business relationship between the healthcare providers and medical translation providers.

The issues in the security of patients PHI

Due to recent technological advancement, the healthcare system has adapted to modern processes and changed its paper-based system with electronic health records. This helped in providing more convenient and cost-effective services to their patients. Aside from that, it also improved the disease diagnosis, patient cooperation, and access to health information.

However, it also puts the patients’ PHI at risk for data breaches and cyber-attacks. Due to the software vulnerability, human errors, and security failures, the important information became more susceptible to unauthorized and malicious people. According to a report,  over 41.2 million healthcare data were illegally disclosed in 2019.

Data breaches also lead to medical identity theft, and fortunately, the latter is preventable. Many healthcare providers are already using RightPatient to identify patients accurately at any touchpoint across the care continuum. However, it can also be used to prevent medical identity theft in real-time by verifying patients’ identities and red-flagging bad actors – protecting patient data and mitigating costs in the process.

Coming back to the point, the medical providers are extra careful when disclosing their patient’s PHI to third parties such as the language service providers (LSP) online. They use encrypted file-sharing or FTP clients for secured data sharing. If they are accidentally sent via email, the message should be deleted from the inbox and deleted folder. Aside from that, all PHI files must be deleted from the LSP’s computer after the project. 

What should you expect from your medical translator?

All the businesses, including the medical translation services, under HIPAA compliance must ensure the security and confidentiality of their project. An LSP’s network of translators must understand the importance of the patient’s privacy and do their best to avoid data breaches. The hospitals must also do a thorough screening to ensure that the translators are HIPAA compliant.

Here are some of the things that hospitals must consider when finding medical translators:

1. HIPAA Training

Ensure the LSP’s medical translators and proofreaders have undergone official HIPAA training. There are numerous training and courses that they could avail themselves of online or even in agencies. If they haven’t done this, the healthcare providers must move on to another company.

2. Experience of Medical Translators

Remember that in medicine, the accuracy and security of information are important. Thus, instead of hiring new applicants, hire seasoned medical translations or a company that can offer expertise in the industry. What’s even better in choosing an agency instead of freelancers is that you can put more confidence in the confidentiality of your patient’s PHI.

3. Business Associate Screening

A lot of medical translation companies claim that they are HIPAA-compliant even if they are not. Thus, it is important to ask for supporting documents and proofs regarding their claims. Make sure that they went through a strict investigation process that verifies their translation management and IT infrastructure.

4. Screening LSPs medical translators

After the agency, the network of medical translators of an LSP must be assessed through a rigorous screening process. The company should have strict criteria and ensure a solid compliant process when finding medical translators.

5. ISO Certifications

Aside from undergoing strict screenings, medical translators need to have ISO certifications. This will help ensure the accuracy, IT policies, and data security of the medical translations. It also certifies the legitimacy of the company that you’re partnering with.

6. Solid IT Infrastructure

It is essential to ensure the sufficiency of the security systems of your LSP. This will help in securing the confidentiality of your patients’ PHI to avoid data breaches in the future. As you know, some medical translation companies use translation software for a faster turnaround of the projects. In these cases, ask for an assurance that these tools will not breach the HIPAA compliance at all costs or just cross it out from the options.

7. HIPAA Audit and Assurance

Aside from the medical translation process, the LSP must have its own way to check the HIPAA compliance of every project. They should also have an extensive process to ensure that there are no errors and mistranslations to the documents. This is essential to ensure that the company is organized enough to ensure the security of the patients’ files.

Time is of the essence when your organization is in the business of saving lives. To improve response time and promote clear and concise communication between all parties involved, you need to make use of a customizable yet reliable computer-aided emergency dispatch system to coordinate with the rest of your team members. 

If you’re in the market for emergency dispatch software specially designed to meet the needs of your EMS organization and improve the services that you provide your clients, there are a couple of things that you can do to make your selection process much faster and easier. One of these is listing down all the features that you want your ideal solution to have. Exactly what features should a dispatch software include so that it can help your institution provide high-quality service during stressful and critical situations? Here are a few that you should consider:

Mobile-Ready

Almost everyone owns a smartphone these days, and more often than not, your staff members access their daily schedules through their smartphones. When you’re dealing with medical emergencies on a daily basis, it is simply not ideal to rely solely on a computer or website to find out what your next schedule or assignment is. Therefore, it makes sense for your dispatch system to feature a mobile app that your team members can access in a heartbeat. 

Once they have the app installed on their mobile phones, your personnel won’t have to log in using a browser every single time just to see their updated tasks. Also, they can receive real-time notifications for urgent assignments. These features, in turn, will help your organization maximize the use of technology and minimize the time you need to provide your services. 

Visual Dispatching

The act of organizing a dispatch can take up a lot of time. Some systems will require you to manually input the time, location, situation, type of vehicle, personnel, and other details that are needed to carry out a proper response, and this can eat up precious minutes. 

Visual dispatching is a much faster alternative to this dated method. Simply put, visual dispatching allows you to click, drag, and drop a crew member’s details to a schedule grid, and your crew member will know about their current tasks or upcoming schedule changes. This method will make it easier for your dispatchers to manage both scheduled and unscheduled assignments that pass through your system. Also, because you can readily see everyone’s timetable, you’ll have an easy time identifying and filling up available slots. 

Multiple Manager Access

Companies that focus on maintaining public health are often open 24/7. EMS organizations typically have to change the schedule of their personnel every now and then to ensure that there are enough staff members to respond to the needs of their clients. This is true with both the EMS crew members on the ground and the dispatchers who coordinate their efforts. 

RightPatient enhances patient identification.

Your online scheduling application, then, should allow more than 1 person to work in an administrative capacity. The system should feature multiple levels of access rights to ensure security. While one person can serve as the system’s primary administrator, the others can be given administrative privileges that they can use when the primary manager is out of their workstation. This way, your organization can continue providing its services even if there’s a sudden change in your staffing schedule. 

Active UHU Percentage

Your dispatch system effectively records the time that your team members are on the clock. This puts it in a unique position to report on Unit Hour Utilization (UHU). This key metric is what most EMS organizations monitor frequently when they have profitability in mind.

Using this metric, EMS organizations can track whether their ambulances are being utilized effectively and whether their crew members are being put to work. To maintain or increase profits, some EMS organizations set a minimum UHU goal to achieve. Besides profitability, this metric also helps dispatchers to allocate resources effectively so crew members are not stretched too thin. That way, crew members can provide better quality care and service even during stressful and critical situations.

Integration with Other Modules

Last but not least, your dispatch software should have the ability to easily integrate with other modules. When every module is sitting on an independent island, numerous IT resources and API calls are needed to get all data in one place. Headaches and frustration arise when you get data integration errors.  Your staff will then have to either fix the issues or key in those data, a highly inefficient process.

At the minimum, your computer-aided dispatch should integrate with ePCR and billing. If that’s the case, then you can improve cash flow dramatically because your billers can bill the dispatch as soon as it is finalized. Also, when your dispatch system is integrated with employee scheduling, you can eliminate the mistakes of assigning someone who is on PTO to a dispatch. These are just a few benefits when you use an all-in-one solution for EMS organizations. 

Conclusion

In order to provide people with quick, efficient, and life-saving services, your EMS organization should be supported by a computer-aided dispatch system that’s designed to meet today’s growing demands. To start, sit down with your team members to list down the essential and nice-to-have features as well as functionalities that you want to see in your next dispatch system. Then, use this list as a guide when checking out your options, or use it to formulate questions when you’re shopping for software providers. Doing so allows you to easily narrow down the vendors that offer concrete solutions to the dispatch system issues that you are facing today.