Volume 1

Keep the Patient at the Center of the Process

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The final piece to this conversation about the documentation in a patient’s record (addressed in the chapter 10 summary) is, “the patient’s medical record that is so important to us, is in fact, owned by the patient. Healthcare organizations have a fiduciary responsibility (as well as a clinical one) to keep this record and the information in it as impeccably as possible.” This is a cause that hospital managers and physicians can get behind together. The patient and his record is a common concern that hospitals can use to unite them with their medical staff. It may not be used often, but it should be. Examples of some hospitals that regularly use the medical record, and in particular, clinical documentation in the record in a positive way to unite managers and physicians is described.

Patient centered clinical documentation means that the organization considers the patient’s interest in his own health information. The patient has the right to request changes in the content of his medical record. Some questions you may want to consider include: How can our organization use this knowledge to ensure patients will be satisfied with the information in their record and not feel the need to request changes? And, how can our organization play a more proactive role in educating patients about quality measures available to them on the Web? This chapter addresses the patient’s rights in his or her health information. These are rights that may not be exercised often by patients today, perhaps because they are not aware of them. But with increased patient awareness about their healthcare rights, this is likely to change. Preparing for this evolution, and even being ahead of it by leading the evolution can help unite hospitals and physicians. These types of cohesive activities are likely to result in a stronger organization overall. The use of an electronic medical record strategy that can appeal to both physicians and patients is also described.