pediatric ehr

3 Tips for Keeping Accurate Pediatric Medical Records

As time progresses, it is becoming easier and easier to keep track of medical records. With the advent of Electronic Health Records (EHRs), it is becoming far simpler to store various metrics about a patient. 

That being said, there can be a huge communication barrier between your practice and other medical providers, and this can make the transfer of medical records more tedious. We will explore three approaches geared at improving the interconnectivity between your practice, your patients, and other providers. These tips will help both your patients and your practice, by providing you with a more holistic view of their medical history.

Tip 1: Educate Your Patients

One of the biggest threats to private practices is the loss of business to Urgent Cares and emergency rooms. A lot of visits to both could be prevented with calls to the primary provider first. - Dr. Robin Warner of Union Pediatrics

Dr. Warner is the pioneer of the 'Call Me First' campaign, in which she hands out business cards and displays posters in her waiting room. This literature encourages her patients’ parents to call her before they reach out to Urgent Care or the emergency room. Ultimately, doing this is more beneficial for her practice as well as her patients’ wellbeing. By calling their primary provider first, they’re getting medical advice from a medical professional who knows and understands them. And by welcoming these calls, Dr. Warner is filling her schedule.

In some cases, visits to other medical providers aren’t preventable. For instance, a patient might have a scheduled surgery from a specialist, or they might break their arm on a day where their primary provider is unable to see them. Under these circumstances, do your patients understand the importance of those visits being documented and shared with you? Dr. Warner’s 'Call Me First' campaign seeks to address this issue by encouraging her patients to request other providers to share the details of their visits with her. This way, if the patient has been prescribed a certain medicine or is undergoing a certain treatment from another provider, the primary physician is aware of what is going on and is able to provide the most appropriate care possible.

Tip 2: Pre-Screen Your Patients

Giving your patients a questionnaire before each appointment expedites their visit and improves the accuracy of their diagnosis. CHADIS is a service that offers various pre-screening questions based on the age and medical history of the patient. Dr. Warner requires every patient to fill out this questionnaire online before each visit. If they fail to do so, she requires them to fill it out on paper in the waiting room before they are seen. Because of this practice, Dr. Warner knows exactly what’s going on with all of her patients before they even walk through the door.

In addition to the CHADIS questionnaire, Dr. Warner asks one additional question to all of her patients before she sees them: “Have you been seen by any other medical providers since you last saw me? If so, when and why?” Upon receiving her patients’ responses, Dr. Warner is able to cross-reference their answers with her own medical records in PCC’s EHR and adjust the patient’s information accordingly. Doing this paints a more accurate picture of the patient’s medical history, which is beneficial to them as well as you.

Tip 3: Make Sure to Request Records from Outside Providers

If a patient sees another provider and they fail to have their medical records transferred, have a plan in place for how you want to acquire those records. In these situations, it would be helpful to have a medical records release template. When your practice discovers that a patient has been seen elsewhere, simply input their information on the template and fax the request to the other provider.

When you are seeking to acquire medical records from a new patient, it is necessary to have them sent to you from their previous provider. But realize that this might not always be enough. This patient could have visited local specialists, Urgent Cares, or emergency rooms, and their previous pediatrician might not have been steadfast in their collection of medical records. So when your practice welcomes a new patient, be sure to ask them if they received care from other providers. If so, reach out to these providers and request all medical records from them as well. Doing so will ensure that you have the most comprehensive medical profile for every new patient that walks through your door.

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PCC has been offering pediatric-specific software, support, and practice management advice for over 30 years. Our goal is to remove the obstacles so that pediatricians can serve communities, improve their practice, and remain independent.