If you’ve ever had a medical procedure or have undergone treatment for a chronic illness, you may have heard your health care provider request to see your medical records. Indeed, even the most basic care requires knowledge of the patient’s past medical history. For this reason, doctors typically request access to these files before agreeing to proceed with medical treatment for any patient.
Why This Matters Even More for Recovering Addicts
Understanding a patient’s complete medical history is especially important for the adequate treatment of addiction. There are many reasons for this – some of the most common include:
- Knowledge of acute or chronic pain issues in patients struggling with opiate addiction
- Diagnostic, procedural and prescription history, to understand where and how medications may have been acquired
- Understanding of kidney function levels in alcoholic patients
Incomplete or inaccurate information about a patient’s previous ailments, injuries, procedures and medical history in the addiction medicine EHR can make for improper handling of medication and overall care for these individuals. This can result in further struggles with addiction including: relapse, decreased likelihood of successful rehabilitation, and even death.
How Providers Can Improve Accuracy
There are many steps a medical provider can take to ensure the information contained in the patient’s addiction medicine EHR are accurate, complete and fully updated. The first and largest step that can be taken is to employ the use of effective and user-friendly medical record-keeping software in their place of practice, to allow all qualified staff to pull records when necessary and add information quickly, as needed.
Once the correct software is in place, some further steps to consider include educating patients on the importance of giving accurate information – even if it may paint them in a negative light – to render proper care, as well as keeping staff full informed on policies regarding the collection of that information and how to handle resistant patients. When providers and patients work together to create a comprehensive picture of past and present care, the outcomes are always better.
