Connecting the Dots with Electronic Medical Charting

Medical charting is the process by which medical facilities keep track of each and every patient interaction. Every person who has been to a doctor’s office in any capacity will have a medical chart. It’s also very common for people to have several different charts. This is especially true for people who have seen multiple medical professionals. As you can imagine, with all that information floating around, it’s easy to miss things or to become confused about a patient's individual visits. Medical professionals have undergone hours of education for keeping things organized, but it’s next to impossible to keep charts streamlined when they pass through so many hands.

In an effort to combat the common problems associated with paper medical charts, medical technologists, doctors, nurses, and software professionals have collaborated efforts in order to develop electronic medical charting systems. Most medical charts contain basic patient information such as name, date of birth, and demographic information such as address and telephone contacts -- anything that might be relevant to medical care. Most charts also contain marital status, obstetric history, and family history. The advent of electronic medical charting has made this information not only easy to gather, but easy to maintain and share. Within the foreseeable future, electronic medical charting will have the capacity to span over multiple practices, thus ending the issue of “here a chart, there a chart” over multiple physicians.

When someone engages in medical charting, additional records are added to the medical chart. Whenever a patient presents with a problem, the primary complaint is recorded, along with the outcome of examinations, any tests ordered, and treatments used. If medications are prescribed, the prescription is recorded in the medical chart, along with the patient's response to the medication. Likewise, the medical chart includes records of surgeries and other medical procedures, along with observations from caregivers.
Medical charting is critical for the organization patient medical history. Doctors use them to identify allergies, risk factors for diseases, and many other health issues that may be relevant during treatment. Medical charts are also used to plan surgeries, subsequent visits, and after care. Medical charting is also used for regular provision of insurance benefits and billing. When a patient is hospitalized, medical charts provides a medium of communication for caregivers on duty round the clock. All of these things could be better served through the utilization of electronic medical charting. This is especially true when care is given round the clock by multiple caregivers on varying shifts (such as in hospital setting or urgent care/emergency facility).