Medical Record Management System

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Recommended: Theories for patient privacy

Within the healthcare systems there needs to be management of access. Every patient encounter does not require access to a patient's entire medical record. Patient's medical records are their personal and private information and they have a right to keep them secure. As healthcare providers, we need to show our patients the respect they deserve as human beings. When caring for a patient it's important to be aware of all the information that is pertinent to their treatment, however there may be things in the patient's record that have nothing to do with what they are being seen for and this information needs to be kept private. Audit trails can prevent unnecessary access to patient's records by requiring healthcare staff to think twice before …show more content…

"Most breeches of confidentiality often occur as a result of carelessness and can be avoided through rigorous control over client records." (Hebda & Czar 2013) Another important use for audit trails is accountability and training. When there are records of who has been in a chart and what they have altered or viewed there are ways of tracking this information. For example, I work in a primary care office and a patient comes in and requests forms be completed by their provider. When they leave the forms I can document in their chart the forms were left with a provider. When this patient calls in a few days later and states they still do not have their completed forms we can go in and track who has been in the patient's record to follow up and find the requested forms. Along those same lines if a patient calls and sends a virtual message to the clinic through our call center, but the message never gets to the clinic, we can go back and track who entered the patient's record and follow up with extra training for the person who did not send the message correctly. The list of benefits of audit trails, in my opinion, much out weighs the

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