Medical Document Management: How to Make and Key Documents

Medical document management plays a critical role in providing quality care, regulatory compliance, and patient safety. After all, with the constant increase in the amount of medical information generated daily, the ability to organize, store, access, and protect medical documents has become a significant challenge for health professionals and managers of medical institutions.

In the face of the advance of Technology in health, growing concerns about privacy and data security, together with constantly evolving regulatory requirements, make it imperative to adopt effective medical document management strategies to ensure the necessary flow of information while protecting the confidentiality and integrity of these sensitive data.

In this text, we will explore the importance of medical document management, best practices, and how technology plays an increasingly crucial role in this constantly evolving scenario.

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What is a medical document?

A medical document is any type of written, electronic, or visual record, information, or record that contains information related to a patient's health, diagnosis, treatment, medical history, and other aspects of medical care. That is, any form of documentation used in the context of health care.

Such documents are also strictly regulated to ensure the privacy and security of patients' health information. We'll see more about that soon.

What documents are considered medical documents?

Medical documents can take many forms. Below, we will discuss some of the most common types of medical documents:

Medical record

The medical record is a comprehensive document containing a patient's health history, including information about appointments, diagnoses, treatments, surgical procedures, exam results, nursing notes, and other details related to the patient's medical care. It serves as a centralized record of a patient's health and is used to track treatment evolution over time.

Recipe book

A prescription book is a document issued by a doctor that contains written instructions about the medications to be prescribed to a patient. It includes detailed information about the medication, dosage, duration of treatment, and any other important guidelines related to medication.

Attestation

A medical certificate is a document that certifies an individual's health condition. It can be used to justify absences from work or school due to health reasons, or to provide information about a patient's fitness to perform certain activities.

Report

Medical reports are documents that detail information about medical exams, surgical procedures, clinical evaluations, and other health-related events. They can be used to document a patient's progress, the results of a specific exam, or the assessment of a health specialist.

Award

A medical report is a document prepared by a health specialist, such as a pathologist or radiologist, that provides a detailed analysis of medical tests, such as biopsy results, diagnostic images, laboratory tests, and others. Reports are often used to support diagnoses and medical decision-making.

The importance of caring for medical documents

As we have seen, medical documents represent critical information that directly impacts the quality of health care and patient safety. Therefore, the correct management of these documents is crucial to ensure that health professionals can make informed decisions and provide appropriate and continuous treatment to the patient.

By storing medical documents in an organized and secure manner, it allows the patient's health history to be available when needed. In this way, different professionals can have access to accurate and updated information, continuing care in a consistent and informed manner.

Thus, when records are well maintained, they facilitate collaboration between doctors, nurses, therapists, and other members of the health team, improving the coordination of patient care.

In addition, good management of medical documents is essential to maintain patients' privacy. As these documents contain highly sensitive medical information, the protection of this data is vital to prevent unauthorized access and the violation of patient confidentiality.

What's the best way to organize and store medical documents?

We already know that effectively managing health files is critical to ensuring fast access and data security. But how to put into practice good medical document management practices?

Check out some tips below.

Systematization

Create a clear and consistent organization system. Classify documents by type (medical records, prescriptions, reports, etc.) and organize them in chronological order. Use file names or descriptive tags to facilitate searching.

Digital documents and cloud storage

Using digital documents facilitates long-term access and preservation, with files being stored in the cloud through secure servers with regular backup.

Na Clicksign, for example, documents signed by the platform can be accessed at any time and from anywhere, allowing good management and quick access to files.

Restricted access

Implement an access control system to ensure that only authorized personnel can view or modify documents. This helps maintain the confidentiality of medical records.

A platform such as Clicksign, for example, allows the user Limit access to a particular account from your IP, providing even more security for the management of medical documents.

Data backup and recovery

Establish procedures to perform regular backups and ensure data recovery in the event of hardware failures or disasters.

How can electronic signatures assist in the medical document management process?

An electronic signature solution plays a significant role in managing medical documents, facilitating signature collection, authorization, and document authentication electronically.

With the electronic signature, it is possible to collect secure signatures from both doctors how many patients, such as informed consents, authorizations, and patient requests. This eliminates the need for paper signatures, making the process more efficient and secure.

Additionally, documents that require approval from multiple health professionals can be submitted electronically for review and signature, streamlining workflow and allowing professionals to securely access and sign documents, even remotely. This is especially useful in telemedicine and remote collaboration scenarios.

Another crucial point is the security of these documents. Na Clicksign, a pioneering electronic signature company in Brazil, the database is encrypted to ensure the security of sensitive data, in accordance with the General Data Protection Law (LGPD). It's no wonder that Clicksign is the only Brazilian company in the electronic signature market that is certified ISO 27001, ensuring the highest information security standards.

In addition, Clicksign provides audit logs that track all actions performed on documents and prevent changes from being made after the document has been submitted for signature.

Do you want to better understand how Clicksign works and the management of medical documents within the platform? Try it free for 14 days and submit up to 30 documents today!