Medical records
NextHealth Care
NextHealth Care
Included in every Care product
A medical record is both a clinical tool and a legal document, and both depend on it being complete and properly controlled. NextHealth Care tracks each record until it is complete, assigning deficiencies such as unsigned notes to the clinician responsible. Every view is recorded with who, when and from where, information is released only with the right consent, and emergency break-glass access requires a reason and is sent for review.
What it covers
- Record completion tracking and deficiency management
- Release of information with consent and disclosure logging
- Retention and archival per regulator requirement
- Full access audit: who viewed which record, when, from where
- Break-glass emergency access with mandatory justification and review
Emergency access is only safe when someone reviews it
Medical records management with a full audit trail
A patient asks who has looked at her record. Instead of a week of searching logs, the records team produces the full access history in minutes: every view, by whom, when and from where, including one emergency access with the doctor's recorded justification and its review.
Clinicians see their own outstanding items, so notes are signed and summaries completed while the visit is fresh, and medical records teams stop chasing paper. Release of information is logged with what was disclosed and to whom.
Break-glass access lets clinicians reach a record in an emergency without waiting for permissions, but every use requires a justification and goes to a review queue, because emergency access that nobody checks is a risk in itself. Retention and archiving rules keep records for the period your regulator requires. Records staff work from clear worklists instead of paper files, so audit requests that once took days are answered the same day.
How medical records management works in NextHealth Care
Health information management (HIM) covers the completeness, security, release and retention of medical records. In NextHealth Care, these controls work on the same electronic record clinicians use, so nothing depends on paper files.
- Track completion. Deficiencies such as unsigned notes are assigned to the clinician responsible.
- Audit access. Every view of every record is logged with who, when and from where.
- Control emergency access. Break-glass access requires a justification and is sent for review.
- Release information. Records are released only with the right consent, and each disclosure is logged.
- Retain and archive. Records are kept and archived for the period the regulator requires.
More in NXH Care
12 more modules
Questions we get asked
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Medical records is included in every Care product: Care Clinics, Care Clinics Pro and Care Hospitals.
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Yes. Every view is recorded with who accessed the record, when and from where, and the history can be produced in minutes.
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It lets a clinician open a record outside their usual permissions in an emergency. A justification is required and each use is sent for review.
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Deficiencies such as unsigned notes or missing summaries are assigned to the clinician responsible and tracked until resolved.
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Yes. Records are released only with the right consent, and each disclosure is logged with what was shared and with whom.
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Yes. Retention and archiving rules keep each record for the period your regulator requires.
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