In the medical and behavioral health industries, record keeping and documentation is a necessity for maintaining quality care. Particularly in fields where large volumes of records must be maintained for several years, even decades, client paperwork can create tangible barriers to treatment. Records themselves are not the problem – it’s how they are documented and maintained that can have negative implications in the treatment of clients. Here are 5 ways paper files can negatively impact client care:
Inaccuracies or missing files. For many behavioral health clients, treatment does not start and stop with a single visit to one facility. Files from court proceedings, case manager reviews, laboratory reports, provider progress notes, and hospital records can be scattered to the four corners, making it difficult to know the patient’s history, needs and progress. For many clinics, there are millions of individual files that need to be maintained, sorted, organized and retrieved. Without a single, integrated tool for managing this magnitude of files, data can be incorrectly input into client management systems, files can be lost and results can get misfiled.
Decreased quality of care. Paper-based systems require a lot of written documentation, manual data entry and frequently are unnecessarily repetitive. With such demanding documentation requirements, focus can easily be diverted from the client to the client’s file – with troubling results. At best, it simply means that a provider has less time to spend on client care in order to meet their documentation requirements. In other cases, it might promote an atmosphere of cutting corners, not following up with clients properly and an overall lower standard of care. Either way, overburdened clinicians wind up providing clients with less than optimal care.
Lack of patient context. Patient context is important to the quality and accuracy of care provided. Critical details may be found in one document that may not be included on another. In the paper-based setting where client records and files are found in multiple formats and locations (both electronic and paper-based), it can take days for information to be synthesized and used to find the best treatment for the patient. Without the ability to quickly search for information and review files in one simple location review files, context gets forgotten.
Timeliness. When a client returns to an inpatient facility, the first twenty-four hours are among the most critical for stabilizing the patient. When that client arrives shortly after the records department closes for the day, more than half of that first 24-hour period leaves the attending provider without access to records, history or other pertinent information that the client may not be able to provide. Once the records department does open, it can take several more hours to retrieve the records. This is all but unavoidable in a paper-based records environment.
Confidentiality. Although the file itself may be difficult to access, once an employee is able to obtain the volume, they have all of the patient’s information – whether they need access to it or not. Exposing the entire record in this way to administrative and clinical staff can violate the HIPAA compliance standards, leaving the practice open to legal issues. Moreover, in the client’s eyes, it demonstrates disregard for their confidentiality.
While record keeping is mandatory and vital to successful client care, the burdens and hurdles presented by paper-based methods can easily detract from the client’s needs. The challenges presented by paper-based documentation places undue burdens on the provider and makes it more difficult to provide a high quality of care for the client. In a climate marked by a need for improved quality of care, issues like timeliness and accurate, contextual care should be prioritized. Client records should be kept in a more streamlined and accessible way that reduces the paperwork burden on the staff and allows them to manage clients – not client records.
Are paper-based files hurting the quality of care your practice can provide clients? Milner Technologies is a leading provider of client records management software that integrates with patient management platforms and other core applications to provide streamlined, timely and accurate client information. Learn more about our solutions for behavioral health or sign up for a free live demo.