Ambulatory care records

Ambulatory Care Records

Ambulatory care records serve an important part in ensuring that patients receive proper medical treatment from their healthcare providers for both the patient and the healthcare provider. Despite the fact that patient instructions are not one of the core components necessary in ambulatory care records, they can play an important role in demonstrating the directions given to a patient by a healthcare professional for follow-up care (Ben-Assuli, 2015). Patient instructions are also important since they keep the patient informed of the upcoming appointment. In case issues arise regarding patient instructions while dealing with paper based as opposed to electronic health records, proper management of ambulatory care records and professional skills remain crucial aspects that help in identifying, tracking, and resolving these issues.

Management of Patient Instruction Records

In some instances, issues relating to the management of patient instruction records may arise when using paper-based records, which are a very rare occurrence where electronic health records are in use (Ben-Assuli, 2015). To identify these issues, I would pay close and keen attention to the reaction and time spent waiting for the retrieval of the records (Fenz, Heurix, Neubauer & Rella, 2014). If patients are made to wait for long hours as their files are located, these would indicate that either there is a wrong filing issue or documents such as patient instructions are being misplaced. Also, crosschecking of multiple files and requesting duplicate copies of the instructions would also be a way of identifying issues.

Addressing the Issues

Once I have identified the issue, I would interview those involved and observe them without their knowledge to establish who is responsible for the problem. I would also track the course of the issues by mobilizing the concerned staff to review all the files and check whether they are correctly shelved or if there is any record left lying about (Fenz, Heurix, Neubauer & Rella, 2014). To solve the issue, I would ensure that the files are arranged afresh, any missing files traced, and all the files placed in their respective area. I would also hold a meeting with the staff to remind them of the importance of proper record management, hold consultations with various medical records experts to forge the way forward and offer in-service training to the staff to avoid the problem in the future.

References

Ben-Assuli, O. (2015). Electronic health records, adoption, quality of care, legal and privacy issues and their implementation in emergency departments. Health Policy, 119(3), 287-297.

Fenz, S., Heurix, J., Neubauer, T., & Rella, A. (2014). De-identification of unstructured paper-based health records for privacy-preserving secondary use. Journal of medical engineering & technology, 38(5), 260-268.