I'm Worried about Faxes and Computerized Records: What Do I Need to Know about Them?

Email and fax are great methods for expediting the transmission of written documents. However, according to the American Health Information Management Association (a division of the American Hospital Association), there are certain safeguards that you should take to protect the confidentiality of your clients when transmitting records using these methods.

Safeguards for Faxing

A quick, three (3) check system for faxing (somewhat like the system used for giving medications) is a handy reminder to use when faxing. It goes like this:

1. Check the number before you dial.

2. Check the number on the fax machine display.

3. Re-check the number before you press the "send" button.

Computerized documentation is as legal as when you manually chart in the medical record.

Are you doing some of your documentation on a computer? I'm sure your answer is a yes. Using a computer to record information in the medical records allows easier communication of that information and also eliminates the problems associated with handwriting that is hard to read. Remember that your computerized documentation is as legal as when you manually chart in the medical record. Therefore, you need to be just as careful in following all of the policy and procedures related to computer charting as when you manually chart. Reducing your legal risk and providing secure computer records is easier if you use the following guidelines (NSO, 2020).

Computer Charting Guidelines

As we leave the topic of computers, it bears repeating that as with any other form of documentation, good computerized documentation not only can help you in court, but it can also keep you out of court in the first place.