Being able to vitalize a medical record into a useful documentation is one of the most powerful traits of a health advocate. Throughout our past conversations, we have continuously addressed the need for medical record organization and why it matters. We also recognize that it is important for health advocates to conceptualize the three distinct layers of medical (health) records and the two that you should master to speak clearly to providers when you cannot.
This article’s goal is to enrich your health advocacy skills that will not only address medical records at face value but disrupt the way you view records and really make your medical records work for you. The in-depth understanding of your medical records, which is meaningful, dynamic, and clearly communicates your governance of past information, will effectively safeguard present and future medical care. If you haven’t already read our past articles on the fundamentals of medical notes, you can do so here, here, and here (in this order). Make sure that you read the background before scrolling down to the pictures. That way, you’ll avoid confusion and learn how to conceptualize the science behind medical records (properly) in the least time possible.
Defining Medical and Health
Before we go on, let’s take a moment to clarify the words medical and health. Although the two words often overlap in meaning, at times they have slight variations. Best practices imply that people should refer to the word medical when discussing services or practices performed by licensed professionals and refer to the word health when indicating an individual’s status (i.e., You may seek medical care services to treat your health condition. Your health is great after following your surgeon’s treatment, so now you see your health and wellness provider regularly).
Medical—Relating to the practice of medicine. 2) Requires professional treatment at any specific point of care. 3) Pertaining to the healing of disease, illness, or sickness.
Health—The status of a living being at any given time. 2) Soundness of the body or mind free from disease or abnormality. 3) A condition of optimal well-being.
A Word About Medical Record Management Services
Many people are already familiar with health clinics and are updating themselves in a digital system. A commonly known consequence of electronic health record implementation is that it divides medical records into two separate competencies. The clinical medical record focuses on condition management that is resolved in the treatment room, while administration management pertains to record governance outside the treatment room, such as financing and insurance plans. It also goes further in layers such as socioeconomic factors, the patient’s ability to adhere to treatment and proficiency in decision making.
Today, many practices realize that their offices are more advanced and have more communication capabilities than their patients. Thus, an additional service emerged, known as chronic condition management (CCM), which is recognized as reimbursable by payers. CCM is a year-long monthly service that provides people with medical record management services. Essentially, this service completes patients’ newly brought-on responsibility to organize medical records themselves. This service is provided for people with common to complex conditions that last longer than 12 months and could use assistance to manage all the administrative work that coexists with their condition. CCM includes faxing, collaborating, professional communication via email, documenting, and recording everything that is medically associated with the patient’s condition.
Before the pandemic, this was something that I would consider an excellent offering. However, this is a service that is completed by professionals for the patient and is stored within the specific medical practice’s electronic health record. The downside of this service is that it could change hands from year to year and limit storage to that particular office’s staff performed. Therefore, this service is limited and should not be used as a patient’s emergency safety net.
If you are qualified for CCM, work with your provider on your health management system. However, if you are not qualified for this service, it is not medically necessary. Therefore, you can create your health record without professional guidance.
Characteristics of Clinical and Administrative Tables
Medical Record Management Assistance (CCM) and the DYI Health Record
Given that many people (especially those who live in rural areas) don’t have access to the internet, fax machines, and a secure portal where clinicians could comfortably communicate records, learning how to create a health record on your own can get overwhelming.
Two Types of Medical Records
Standard—A standard medical record is a collection of notes and recordings created by a licensed professional to document their patient’s history, diagnosis, treatment, or progress. Standard medical records are usually stored in an electronic system and limited to a single provider’s entries in a particular point of care.
Non-standard—A non-standard (health) record consists of entries, notes, recordings, and other standard documents that are collected by people who do not have a license to practice medicine, go uncompensated, and are not formally trained in healthcare. Individuals who collaborate on this kind of record cannot be recognized in a court of law. However, non-standard medical records are important and can be an extremely informative communication tool throughout the entire care team.
Three Tiers of Medical & Health Management
You can rely on the provider to record the clinical information and services performed, as well as provide the patient education needed in the treatment room. When medical management data are captured, they are stored in-house (usually) electronically. Your provider has the lion’s share of leadership in the medical management and treatment department.
Individual (Health) Management
Your individual management is completed by an initial audit of all health documents. To begin this process, start by creating a cover page for yourself (please see the Patient Better Health Proxy Tool) and collaborate on preexisting documents, or keep a record of 1) your unique social circumstances (i.e., religion), 2) lifestyle (i.e., your job—if under unique circumstances), and 3) family and medical history.
Family (Health) Management
This is a three-fold approach for individuals with long-term, complex conditions to ensure that the individual and the family member caregivers are in the best possible physical, emotional, and mental well-being throughout all stages of diagnosis. Although others’ health information does not belong in the individual’s health record, it is good to be cognizant of the ones who are helping with organizing, collaborating, and documenting one’s care.
- The health advocate’s core foundation is the ability to create a health record in the best possible way to communicate with professionals.
- Organizing medical records is multilayered and sometimes requires analysis.
- If you are incorporating a family member into care management, ensure that he or she will help by practicing self-care while caregiving for another.
Did you like what you just read?
Patient Better’s mission is to get everyday people to become expert health advocates. I would like you to allow us to teach you how to manage your records independently. Today, it is imperative that you learn to become self-reliant and safeguard and protect your medical data and your health history. It is just as important to readily supply them to professionals in emergency situations. Please read Health Safety and Emergency Preparedness 101.
About Patient Better
Patient Better is a 501(c)(3) nonprofit organization developed to help offset some of the new challenges facing patients and their family-member caregivers in navigating throughout the healthcare industry. Our mission is to provide affordable health management knowledge and equip people with unique, lifelong skills to independently manage care efficiently and effectively.
If you want to learn more about how you can become an expert health advocate (for in-person and virtual medical appointments) visit patientbetter.com.
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