There has been a perpetual pandemic across healthcare institutions worldwide since the practice began. It is that of misdiagnosis and misinterpretation of medical reports. Statistics show that nearly 40,000 to 80,000 people in the US die due to misdiagnosis annually. As if that wasn’t bad enough, 12 million suffer from diagnosis errors in primary care, with 33% leading to death. Many solutions have been proposed to this problem, but none have come close to solving it as medical record indexing does.
Medical records form the backbone of medical diagnosis, helping doctors unfamiliar with a patient to understand their problems quickly. If these records are in order with all of the necessary information and reports intact, then the treatment received by the patient will be accurate and quick. Otherwise, it will lead to medical care professionals establishing their treatment plans on unconfirmed medical history or unreliable information. This leads to a situation similar to misdiagnosis or delays in treatment. Additionally, inaccessibility to such critical documents impacts the entire operational structure of a healthcare firm, including departments like billing, accounting, pharmacy, pathology, etc.
Thus, proper indexing is necessary for every medical institution to keep it from adding to misdiagnosis statistics. Here is a quick guide about how it works and why outsourcing medical records indexing service can be a critical advantage for healthcare firms.
The True Definition of Medical Records Indexing
Technically, Medical Records Indexing is the process of arranging and maintaining a patient’s medical reports in a pre-defined order. The standard methodologies of categorizing medical records can be chronological, alphabetical, numerical, by physician specialty, physician Name, DOS, etc. There may even be custom organizational methodologies applied whenever needed.
Laws Applicable to Medical Records Maintenance
In the US, the government mandates that a physical copy of a patient’s medical records be maintained for a minimum of seven years. That period could extend to 10 years. This makes it important for medical professionals and facilities to have an effective process that ensures that medical record maintenance laws are followed.
The law also mandates that the medical facility should be able to produce the necessary documentation to concerned representatives if the same is demanded. Doctors/medical facilities must furnish physical and electronic documentation related to orders, certifications, referrals, prescriptions, and payment requests. Medical records indexing services become necessary here. That’s primarily because safely storing documentation for patients across a decade and ensuring easy accessibility in such a database is a grueling task.
Reasons to Index Medical Records
An easily accessible copy of the patient’s medical records is beneficial in various cases. Hence, it necessitates the need to have indexed medical records in place.
- In legal scenarios, it helps lawyers to litigate on behalf of a patient’s case if the record is appropriately aligned. Crucial information from them promptly helps make pertinent arguments against the defendant.
- It helps ensure HIPAA compliance along with other applicable laws easily.
- It makes medical billing and scripting hassle-free since all necessary information will be easily accessible. This helps insurance companies process claims quickly too.
- Database management of the entire facility becomes easier as there is certainty about the required infrastructure.
- Monetary losses are prevented since operations relevant to medical record maintenance and submissions aren’t repeated. Also, the certainty regarding data infrastructure requirements saves money on unnecessary excess expenses.
- Document loss won’t be an issue since each one will be indexed based on a standard, thereby consolidating its position and category.
- Enables the accurate statistical measurement of important data points.
- It helps group patients into specific market segments.
- Financial investments, particularly passive ones, can be based on indexed records since they confirm otherwise ambiguous data.
- It helps with digitizing the paper version of the documents as the order for entry will already be present. Simple scanning and uploading are required, besides any additional data entry.
- Transfer/sharing of pertinent files between various stakeholders, like patients, administrators, specialists, government agencies, and insurance agencies, is simplified, and corresponding data sections can be forwarded to them.
- The operational efficiency of the entire establishment improves since there is a continuous flow of accurate information between its various departments.
- Data archival also becomes easy as the correct documents can be identified and stored for later use.
- Collaboration between various suppliers/vendors/partner businesses and others becomes seamless due to the clarity of information and quick transferability of digital documents.
- The operational efficiency gains and data accuracy due to indexing reduce unwanted stress on the facility’s staff. It improves overall morale, engagement, productivity, and employee retention rates.
The Processes Involved in Medical Record Indexing
Medical records are documents with a variety of data in large quantities. Indexing such a vast trove of paperwork requires that multiple steps are followed. Each of these steps is performed based on the medical facility’s needs. Hence, there is some element of customization over and above the standards that must be followed.
The following are the document types that undergo indexing:
- Primary Medical Records
These are the coded documents containing information about a patient, their treatment, the medication used, etc. This type of document is used for multiple purposes like updating the patient’s health records, billing, research reference, and legal cases. Therefore, this type of document takes the most time to be processed by medical records indexing services as there may be a variety of categories to segregate them.
Radiographs are the documents produced whenever tests like X-rays and MRIs are conducted for diagnosis purposes. They contain images that aren’t regular photographs and require special training to read. These come in the form of films and disks. These are indexed according to criteria like dates of service, type of radiograph, and storage location. Every disk and film of radiographic documentation is assigned a unique reference number for easy identification and retrieval.
- Pathology Specimens
These are rather special since an actual specimen accompanies the relevant document. These documents contain details about biopsies and surgical resections submitted for diagnosis purposes. Hence, they are classified similarly to radiographs. The categories include the date of submissions, the location where the specimen is accessed, and its number.
These documents are not directly associated with the medical industry, but they come into play whenever a litigious process is involved. They are the documents that are filed with a court during a litigation process.
They undergo medical record indexing differently than the rest of the bunch. Their indexing occurs by ascending numbers as directed by the attorney in charge. And they are filed in reverse chronological order. Other pertinent medical documents are attached to pleadings during indexing.
The following steps are adopted to perform indexing:
- All of the documents to be indexed are collected and closely scrutinized. The data present in them is analyzed in terms of the provided medical treatment, service providers, dates of encounter, and other such parameters.
- The Electronic Medical Records are then classified into multiple sections and subsections as desired by standards and the healthcare facility’s policy.
- The documents are sorted according to the date range that applies to a particular section.
- Duplicates are removed to maintain documentation hygiene.
- If there are legal documents involved, then the attorney’s requests are considered.
- The documents are assigned page numbers for correct reference of their content. This process is called pagination. This step is crucial as it provides the reference points for each bit of information that is essential for easy navigation by relevant personnel.
- Hyperlinks to important reference points are also added during the medical records indexing process to easily navigate those sections and timelines in the referenced source medical records.
- Once the documents are in order, multiple copies of them are made for record maintenance and distribution to all relevant parties. These are labeled according to a fixed standard so that they aren’t confused with other duplicates that need to be removed.
The healthcare industry’s ever-evolving nature is a boon to patients since they expect better treatment as the days go by. This includes the improvements made to medical record maintenance and distribution. With the advent of personal health monitoring devices that constantly generate patient data, the need for accurate and quick indexing is only becoming more valuable. Hence, hiring an experienced service provider for data management is a top priority for healthcare facility administrators to maintain profitability and foster better relationships with all concerned parties.
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