An Overview of Medical Charting Software

In recent years, more and more healthcare organizations are embracing the use of healthcare information technology to handle their medical charting needs. EHR software solutions allow physicians to improve the quality of care they provide, reduce charting errors and spend more time focusing on the patient rather than documenting by hand. As pen-and-paper charting is slowly phasing out, health facilities are using medical charting software to document patient information more efficiently, helping lead to an increase in daily traffic as well as revenue opportunities.

Now more than ever, access to a patient's complete medical history is an essential need for both nurses and doctors. Because paper records are more prone to mistakes and handwriting/legibility issues, medical charting software is a useful tool to ensure accurate and up-to-date patient information. This, in turn, leads to more accurate diagnoses and effective treatment plans, allowing your physicians to increase patient satisfaction consequently.

Considering the expensive state-of-the-art medical equipment that most clinics and hospitals use, it's surprising that certain medical practices and hospitals still rely on paper records to keep track of their patients' medical histories.

Today, medical software advancements allow your physicians to automate the entire charting process, making information easy to collect while keeping track of your patients' medical records. It's now up to the clinics and practices to make use of the technology that's available. But first, let's discuss what medical charting systems are and more of what they do.

What Is Medical Charting Software?

A medical chart is simply a complete record of a patient's clinical data and medical history. Patient charting keeps patient information on file, including demographics, vital signs, diagnoses, medications, allergies, lab/test results, treatment plans, immunization dates, progress notes and more. Accurate medical charts help ensure the systematic documentation of a patient's medical history along with his or her medical history, diagnosis, treatment and overall care.

Medical charting software allows you to conveniently and efficiently store patient medical histories, test results and medication information. In essence, the software is an electronic medical records (EMR software) or electronic health records (EHR software) system, which serves as a digitized version of a typical paper chart that would have to be stored, transported to doctor's offices and filled out by hand. It's worth noting that the terms EMR and EHR are used interchangeably by industry insiders.

An EMR/EHR solution helps to keep all of a patient's data in one place, making it convenient to access, analyze and edit at any given time. Charts can be edited in real time, ensuring anyone who accesses the software has the most accurate and up-to-date patient information. As a result, any changes become visible in the system immediately. Medical history can be transferred from one department to another, or even between different clinics or hospitals.

What Information Is Included in a Medical Chart?

While we've discussed some of the basic information stored in a medical chart, it's worth noting there are is a wide variety of patient information that is kept on file, from personal information to medical history and so on. Medical charts contain any medically related events a person has experienced. These charts should paint a clear picture of the patient for physicians and other software users. The information provided in these charts helps healthcare professionals to make informed decisions when it comes to treating their patients.

Here is a list of information typically included in medical charts:

  • Demographics: Name, age, contact, etc.
  • Medications: Current and previous
  • Allergies: Including any potential drug-to-allergy interactions
  • History
  • Family History: Immediate family's health, causes of death, common diseases
  • Surgical History: Operations, dates, reports/results
  • Social History: Occupations (current and past), community life, etc.
  • Developmental History: Motor skills, cognitive, social/emotional, language, growth charts
  • Obstetric History: Number of pregnancies, outcomes, complications
  • Immunization Records: Vaccination dates
  • Habits: Drug use, smoking/drinking, sexual history, lifestyle

Who Has Access to a Medical Chart?

When it comes to sensitive data such as an individual's medical information, only the patient and the healthcare professionals directly involved in that patient's care and treatment should be allowed access. Medical charts belong to the patient, who has the right to make sure their chart is accurate - if they find inaccuracies, they can petition their providers to make changes to their chart to ensure more accurate medical records.

Benefits of Medical Charting Software

The use of medical charting programs is very advantageous to almost every health organization, with a variety of benefits for both physicians and patients. Good EHR/EMR systems alert healthcare professionals of any missing, incomplete and inaccurate medical charts.

Here are some of the primary benefits and advantages that come with the use of a comprehensive medical charting software solution:

Accessibility to Health Information

A medical charting system makes it easier than ever to share patient information between doctors, specialists and even different departments. Everything is digitally stored and available on demand so doctors can instantly view data, including patient histories, known allergies, previous procedures, used medications, test results and anything else that might be relevant to treatment or diagnosis.

By simply logging in to the system, a specialist can instantly gain access to an online medical chart without having to wait for it to be delivered or faxed. This would be impossible with paper records, especially when numerous tests and procedures are involved in different departments. The amount of paperwork involved makes it likely that some piece of information would be lost in the process. But with an EMR system, everything stays safely stored in one place.

Physicians can also easily sort through information using keywords or terms, which allows them to quickly locate the information they're looking for, instead of sorting through multiple pages of records.

Improved Diagnosis and Treatment

When medical charting software is properly implemented, it can result in a significant improvement when it comes to the diagnosis and treatment of patients, while at the same time greatly reducing the number of errors made when filling out patient charts. Oftentimes, errors and handwriting/legibility issues within a medical chart can lead to an incorrect diagnosis and have the potential to create further problems for patients. EMR/EHR software greatly reduces these errors within medical charts.

Owning a system that ensures accurate patient information and other data is a big benefit on its own. What's more, without the usual limitations of space that are common with paper records, EMRs allow you to include all the necessary information that could be useful in the future.

Many EMR/EHR software solutions also include health analytics and population health tools to help your facility improve its quality of care. These analytics can also compare the performance and effectiveness of your professionals as to other organizations.

Security of Information

Paper records are always at risk of accidents and various hazards. For example, a fire or a flood could wipe out an entire hospital's patient histories without any chance of recovery. Paper medical records can also be misplaced, lost, stolen or tampered with, which can result in greatly reduced effectiveness of patient care.

This problem is eliminated with the introduction of an EHR or EMR. These records come with frequently updated recovery databases so that, even in the case of a system failure, all of that data can usually be recovered.

Obviously, electronic systems have their own vulnerabilities, particularly in terms of potential unauthorized access. However, many provide limitations as to who is granted access to patient files, typically sticking to a need-to-know basis. But the security systems that are in place for the leading EMR solutions can usually keep the data safe from security breaches.

Increased Productivity

EMR systems can help clinics and practices increase efficiency in multiple ways, which in turn, results in an increase in productivity and enhanced patient workflow. The ability to quickly fill out medical records using EHR/EMR software solutions can help doctors spend more time with their patients and provide a more accurate diagnosis.

This can also have a compiling effect over time. Since patient history is conveniently located on a digital platform, patients won't have to waste their time or that of their doctor's by explaining their problem over and over again. That information is filled out during their first visit, and it can quickly be updated according to the progress without the need to write everything out each time.

By spending less time documenting and charting, physicians are able to focus more of their efforts dealing with the patient. This speeds up office visits, allowing your organization to increase its overall traffic as well as revenue opportunities.

The advantages of electronic records over traditional paper records don't end there. These solutions also allow you to establish a standardized documentation practice of patient care within the entire clinic. It also enhances data mining, quality improvement and biovigilance monitoring, among other things.

In Conclusion

Medical charting software has helped a wide variety of health organizations increase their productivity and efficiency, enabling their physicians to provide better care and increase revenue opportunities. These solutions allow your staff to streamline daily operations without sacrificing the attention given to patients.

While the benefits of an electronic medical records system are clear, finding one that's right for your practice depends on your individual needs. It's important to involve all potential users to determine the unique needs and wants of your employees. Consider taking a look at our EMR software requirements checklist when contemplating potential vendors.

Still have questions relating to medical charting software? How has your organization benefited from these solutions? Let us know in the comment section.


Source: An Overview of Medical Charting Software, SelectHub, by Jason Keller, January, 2020.

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