Every time a patient visits their doctor, their medical chart is updated. Maintaining a patient’s medical chart is crucial to practicing medicine. Healthcare providers cannot make data-informed recommendations regarding a patient’s health without an accurate medical chart available. 

In the past, medical charts were paper documents handwritten by a provider. The problem with manually handwriting medical charts is that information can easily get lost or entered incorrectly, leading to friction in the patient experience. That’s why today, medical charts are primarily entered and stored securely in a digital format with HIPAA-compliant medical charting software.

Medical charting software makes it easy to retrieve and share patient data in a secure environment. In addition, medical charting software should allow for seamless sharing of a patient’s records with their other healthcare providers. Medical charting software also enables physicians and medical staff to streamline the medical charting process to keep a complete record of a patient’s medical history.

This article will explain what medical charting software is, how the software streamlines medical charting tasks, and the benefits a medical practice like yours can expect from adopting it.

What is medical charting? 

Medical charting is when providers document a patient’s medical history and update it with each visit. Medical charts can keep track of a wide range of patient health information, including:

• Medical history. The medical history usually contains everything from a family history of hereditary diseases, past hospital visits or surgeries, and any other previously documented illnesses, medical procedures, and diagnoses.
• Patient demographics.  Keeping an accurate record of a patient’s details, such as their name, age, address, and phone number is essential for medical billing and follow-up care.
• Chief complaints. A chief complaint could be a new health concern, such as the patient experiencing pain or other symptoms.
• Laboratory results. Medical charts typically include lab results and tests such as blood tests, urine tests, and imaging studies.
• Vitals. At each visit, medical practitioners will typically record a patient’s blood pressure, weight, and heart rate.
• Medications. Patient charts keep a record of current and past medications for a patient. That medication history helps clinicians identify and prevent contraindicated drug interactions.
• Allergies. What the patient is allergic to, including certain drugs, foods, or medical materials such as latex, is important to know when prescribing medications and otherwise interacting with the patient.
• Health behaviors. Certain habits, such as substance and alcohol abuse, can put a patient at risk for certain diseases. Patients who smoke, for example, may not be eligible for elective surgeries.
• Immunization records. Medical charts help patients keep track of their vaccination dates over time as well as upcoming recommended vaccines.
• Obstetric history. Pregnancy can drastically impact a person’s overall health. Medical charts will indicate if the patient has ever been pregnant and if there were any complications during or following the pregnancy.

It’s important to note that a medical chart includes private, sensitive information only accessible by the patient and their healthcare providers and is protected under HIPAA compliance. That means that information cannot be shared without the patient’s consent and must be stored safely and securely whether it is a physical or electronic record.

What is medical charting software? 

Medical charting functionality is commonly found within electronic health record (EHR) software and offers a secure, digital form of a patient’s medical history and information. Though sometimes referred to solely as standalone “medical charting software,” most medical practices utilize an EHR for their medical charting needs. 

This software reduces data entry errors, prevents friction in the patient experience, and helps ensure a medical practice’s compliance. Though EHRs are the standard software solution for medical charting today, they weren’t always—originally, electronic medical records (EMR) were the first adoption of digitizing medical charts. 

Learn more about EMRs and how they evolved into EHR software below.

Related Content: EMR Vs. EHR: What’s the Difference?

Benefits of medical charting software

Medical charting software offers numerous time-saving and accuracy benefits. It enables clinicians to access and update patient information within a single database quickly in real-time. Some medical scheduling software also provides templated intake forms and charts, helping streamline data entry and reduce the time clinical teams require to update charts. 

Electronic medical charts empower patients to take active roles in their healthcare. Patients can access their medical charts to track their progress as they make lifestyle changes. That access improves communication and transparency between providers and their patients, building stronger relationships and trust. 

With electronic health records, if patients find an error in their chart, they can ask their provider to revise it. EHR medical charting also saves patients and providers time on intake. For example, if a practice refers a patient to a specialist or a different department, the practice can send their existing EHR medical chart to the new provider.