For patient care, it is important that you begin by assigning a unique code to each of your patients. As this information should be kept confidential, it is important that you know where to look it up every time you want to make changes or track previous health records. The code could be a patient’s Social Security number, name, date of birth, company number or any code you want, which provides a unique identity to each of your patients.
If you are writing this information down, you can file it in a folder, or use custom designed software which can be much more efficient.
The traditional method has long been overtaken by computer software, allowing medical staff to prepare and maintain reports in a timely and effective manner. However, most companies will use both methods for record keeping.
If you are preparing health files, make sure that you label them sequentially in order to keep tabs on your current and inactive patients. For larger medical institutions, software may be a suitable option, allowing them to maintain an extensive database for all patients.
Microsoft Access has specifically been used for this purpose but there are other softwares available in the market which allow you to do the same. If you decide to use software, make sure your staff is trained for it.
If you are preparing a medical file for yourself, it is important that you write down your current medical condition in detail. This should be on the first page, along with emergency contact information and the name of your doctor. After that, you should list the current medication therapy. Make sure you include your prescriptions and specify if you are allergic to any medicines. Get copies of all your medical records from the health clinic or hospital and include them in the file.