Improving patient care through effective medical records management: A nursing and physician perspective

Abstract

Background: Health information also oversees a very important function in relation to the safety of treatments and the general quality of a healthcare service. Over the recent past, with the adoption of Electronic Health Record (HER) with the decrease in the use of paper documentation there have been advancement in the documentation of health records from easy access to accurate documentation. Aim: This study seeks to understand how to improve the chances of positive health outcomes through the management of medical records on the part of health care givers; and potential strategies of interest include the views of stakeholders and benchmarks concerning management and ways of preserving the identity of patients. Methods: As a result of the literature review, the findings of studies on the effectively and ineffectively implemented HER system, records management by interdisciplinary teams, and measures of maintaining confidentiality of patients were reviewed. Results: The study also revealed that accurate medical record keeping play a very vital role to enhancement of health care delivery and work effectiveness. Increased use of technology especially in implementing EHRs has enhanced ways of accessing information, decision making and communication in a team.

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