Managing Information Technology Book
This documentation is placed in the patient’s chart and is available for the practitioner to review at the next visit. This provides for continuity of care in the event that another health professional in that office sees the patient as well as refreshes the same practitioner’s memory about the care he/she has provided for the patient.
Results from laboratory tests, X-rays, other diagnostic tests as well as a list of medications or treatments prescribed are also contained in the chart. In addition to this information, the chart will also contain any paperwork the patient completes, such as a family medical history, insurance information and consents for treatment, authorization to share information, and so on.
New Office New Chart
If the patient sees another health care provider, such as a specialist recommended by the primary care practitioner, a new chart is created and most often there is no integration of the information with the other physician's chart. If the patient is hospitalized, another chart is created. Each health professional creates a new chart or file for the patient and often has to reinvent the wheel to get a complete picture of the patient’s health history.
If the patient obtains medications from several different pharmacies, there is not a complete profile available at any of them. This sometimes results in medication errors from issues such as duplication of medications, or unknown medication interactions.
Oversight Not a Reality
Patients who have primary care providers who are willing and able to oversee the total care of a patient will have records sent from all sources of care each time they see another provider and review them. This is cumbersome, time consuming, and not reimbursable. In reality it does not happen often.
Most patients are not versed in medical terminology. Often they barely understand a diagnosis or treatment. Some things may seem totally insignificant and are forgotten, such as a visit to the Urgent Care for a virus or to the ER for a sprained ankle, and the information doesn’t get passed on to the primary care professional. A complication that could stem back to this illness or injury may never be connected.
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