How can you ensure accurate patient records when transitioning between care settings?

1 Use standardized tools and processes

One way to ensure accurate patient records is to use standardized tools and processes for collecting, documenting, and sharing information across care settings. For example, you can use a discharge checklist, a medication reconciliation form, a care plan template, or a transition of care report. These tools can help you capture the essential data, identify potential gaps or errors, and communicate clearly with other providers and patients.

2 Leverage technology and interoperability

Another way to ensure accurate patient records is to leverage technology and interoperability. Technology can help you access, update, and transmit patient records electronically, reducing the risk of manual errors, duplication, or loss. Interoperability refers to the ability of different systems and devices to exchange and use data. You can use interoperability standards, such as Health Level Seven (HL7), to facilitate the transfer of patient records across different platforms and formats.

3 Involve patients and caregivers

A third way to ensure accurate patient records is to involve patients and caregivers in the transition process. Patients and caregivers can provide valuable information, feedback, and preferences that can enhance the accuracy and completeness of the records. You can engage them by educating them about their condition, medications, and follow-up care, asking them to review and confirm their records, and encouraging them to share their records with other providers and services.

4 Collaborate with other case managers

A fourth way to ensure accurate patient records is to collaborate with other case managers who are involved in the transition process. Case managers from different care settings can work together to coordinate care, exchange information, and resolve issues. You can collaborate with other case managers by establishing regular communication channels, sharing best practices and resources, and participating in joint training and quality improvement activities.

5 Monitor and evaluate outcomes

A fifth way to ensure accurate patient records is to monitor and evaluate outcomes of the transition process. Monitoring and evaluating outcomes can help you identify and address any problems, gaps, or discrepancies in the records, as well as measure the impact of the transition on the patient's health and satisfaction. You can monitor and evaluate outcomes by using indicators, such as readmission rates, medication adherence, patient feedback, or quality of care measures.

6 Update and maintain records

A sixth way to ensure accurate patient records is to update and maintain records throughout the transition process and beyond. Updating and maintaining records can help you keep track of the patient's progress, changes, and needs, as well as ensure compliance with legal and ethical requirements. You can update and maintain records by reviewing and verifying the data, making corrections or additions as needed, and storing and disposing of the records securely and appropriately.

7 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?