Things to consider when defining a digital medical record structure

The purpose of a medical record is to record vital patient information for future reference. If these notes are incomplete, or disorganised, it can lead to wasted time and even mistakes.  
Medical records provide a comprehensive history of each patient, and are used by hospitals throughout the life of the patient. The quality of paper based medical record keeping in the UK is highly variable across the NHS and currently the layout of documentation is different between hospitals.  

A digital medical record replaces the traditional paper based filing system. The size of a patients paper file varies drastically depending on how much care they have received throughout their lifetime. Therefore, it is important to consider the vast array of different file sizes and varied structures you may need to digitise.  

There are many key things to take into consideration when defining your digital medical record structure. Here are a few key things to consider: 

  • Review any structures already in place at associated organisations already working within a digital environment. This potentially allows you to use a proven structure, in addition it can facilitate the future sharing of information. 
  • Decide whether you will continue to use the same structure predefined in your current paper based legacy documents, or whether you will implement a new structure for the digital records. 
  • Identify the key documents in the legacy documents that will be referred to in the future and that are worth classifying and identifying individually. These could be:  
    • Operation notes 
    • Discharge summaries 
    • Letters and referrals 
    • Clinic notes etc 
  • Review the Standards for clinical structure and content of patient records published in July 2013 
  • Decide what Metadata will be attached to your documents and by what method will you capture this data. Ensure the data is suitable for your organisation. Data capture examples include:
    • Bar codes 
    • Optical Character Recognition (OCR) zones 
    • Intelligent Document Recognition (IDR) using Pattern matching 
    • Optical Mark Recognition (OMR)  
    • Intelligent Mark Recognition (IMR) 
  • Consider how will you deal with documents “born digital”. 

The key point to remember is to allow broad clinical engagement at all levels, ensuring that all involved buy-in to the new structure and way of working. The reason medical records are kept is to allow for easy access to historical data. Therefore, any new record structures need to provide access to data easily, and the best way of ensuring this is to involve those who will need to access it. 

For more information on any of the topics discussed in this article, or for more information, don’t hesitate to get in touch. Scandox can provide support in defining your digital indexing structure.