Seven Reasons to Standardize Medical Records

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Jul 18th, 2023

The electronic health record (EHR) is widely used for documenting and managing the patient’s medical record. In the 1980s, the first web-based EHRs were being introduced and used in healthcare facilities because computer hardware had finally become affordable. Through ongoing government influence and incentives, such as The Centers for Medicare & Medicaid Services (CMS) Meaningful Use (MU) program,  providers who were early adopters of an EHR, and met certain program requirements, received monetary incentives. Today, lack of an EHR is almost unheard of; however, some providers continue to handwrite their medical reports.  

In today’s digital age the standardization of medical records has become an essential aspect of healthcare management. Standardizing medical records involves the adoption of consistent formats, terminologies, and data exchange protocols across healthcare providers, ensuring seamless sharing of patient information. This article explores seven reasons why standardizing medical records is critical for enhancing healthcare efficiency and improving patient outcomes. 

1. Structure, Format, and Legibility

There are many document types (e.g., operative reports, admission history and physical, discharge summaries, clinic notes) and each has a unique format that includes the use of section headers. Section headers organize a medical report into areas of similar information, such as history of present illness; past medical, family, and social history; active problem list; current medications; etc. When we add structure and formatting to medical reports they become useful documents to other providers, the medical coders who translate diagnoses and services into billing codes, and even to the patient who may need to move or transfer care. Font selection and text size also play an important role. For example, the fonts Verdana and Times New Roman are most commonly used in medical reports due to their wider letter length and spacing, making the medical record easier to read. Additionally, templates provide structure and consistency to medical reports by providing an automatic outline for providers to use when documenting the details of the services rendered. 

2. Interoperability and Continuity of Care

Standardizing medical records promotes interoperability, enabling the secure exchange of patient information between different healthcare systems, providers, and settings. With standardized records, healthcare professionals can access comprehensive patient data, including medical history, allergies, medications, and test results, regardless of the patient’s location or healthcare facility. This seamless flow of information facilitates continuity of care, reduces errors due to incomplete or inaccurate data and enhances healthcare decision making, while reducing costs by not duplicating labs, imaging, or other testing. 

3. Enhances autonomous and computer-assisted coding (CAC)

CAC systems rely on software algorithms to assist human coders in assigning accurate medical codes to patient records. These systems analyze clinical documentation, lab results, and other relevant information; providing suggested codes based on predefined rules and guidelines. Human coders review and validate the suggestions ensuring coding accuracy and compliance. Autonomous medical coding takes automation a step further by leveraging artificial intelligence (AI) and machine learning algorithms to independently assign medical codes without human intervention. These systems learn from vast datasets, continuously improving accuracy and efficiency over time. While these systems reduce reliance on human coders for routine coding tasks, optimizing resource allocation; coding professionals can then be redirected to more intricate cases, quality assurance tasks, or coding audits where their expertise can yield greater impact. This redistribution of resources improves productivity and cost efficiency. 

4. Efficient and Streamlined Workflows

Standardized medical records simplify and streamline administrative tasks for healthcare providers. By adopting uniform data entry formats and coding systems, medical professionals can efficienty capture and retrieve patient information, reducing the time spent on manual data entry and paperwork. This streamlined workflow allows healthcare teams to focus more on direct patient care, leading to improved productivity and increased patient satisfaction.

5. Enhanced Patient Safety and Quality of Care
Standardizing medical records plays a vital role in improving patient safety and the overall qualify of care. With standardized records healthcare providers can easily identify potential drug interactions, patient allergies or previous adverse reactions, minimizing medication errors and adverse events. Moreover, standardized records enable evidence-based decision-making as healthcare professionals access standardized clinical guidelines and protocols, such as those required through the Appropriate Use Criteria Program, leading to more accurate diagnoses and appropriate treatment plans.

6. Facilitating Research and Population Health Management
Standardized medical records are a valuable resource for medical research, population health management, and public health initiatives. By aggregating de-identified data from diverse healthcare settings researchers and public health authorities can analyze trends, quickly identify disease patterns and outbreaks, and develop evidence-based strategies for preventive care and healthcare resource allocation. Standardization also facilitates data integration and supports large-scale studies that may lead to advancements in medicine and public health interventions.

7. Results in Cost Reduction and Better Resource Allocation
Standardized medical records contribute to cost reduction by minimizing duplicate tests, unnecessary procedures, and administrative overhead, not to mention leading to more accurate code selection, improved coder workflows, and less physician queries. When healthcare providers have access to complete and accurate patient information they can make more informed decisions, avoid duplicitous diagnostic testing, and provide more targeted treatments. It also facilitates efficient resource allocation, enabling healthcare organizations to optimize their operational processes, allocate staff and equipment more efficiently, and reduce excess costs.

The standardization of medical records offers numerous benefits for healthcare systems, providers, and patients. By ensuring interoperability, improved workflows, better patient safety, supporting research endeavors, and optimizing resource allocation, standardized records contribute to improved efficiency, quality of care, and especially patient outcomes. As we continue to adopt this digital transformation it will become even more necessary for us to adopt standardized medical records in order to achieve a more efficient, connected and patient-centric healthcare system. 

For additional information on standardizing medical records, join us for our next webinar, "Formatting and Documentation Best Practices" scheduled for Thursday, July 20, 2023 @ 10:15 AM PT, 11:15 AM MT, 12:15 PM CT, 1:15 PM ET. Click HERE to register for this FREE webinar.

About Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Aimee L. Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. Aimee believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.