Importance of Medical Documentation

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					     Importance of Medical Documentation

     By Denise Wang
     eHow Contributing Writer
     Article Rating:                 (0 Ratings)

     Proper and adequate medical documentation is essential for quality of medical care and health care services
     throughout the industry, from receiving proper and correct treatment to receiving payment benefits from
     your health insurance provider.

     Function of Medical Documentation
1.              Why is important medical documentation vital? Without it, your health care would be
     compromised. One doctor wouldn't know what another doctor was doing. Without adequate documentation
     of visits, lab tests, treatments or surgeries, quality of care would certainly be erratic and potentially deadly.
     Medical documentation generally provides all the information about a specific patient that any doctor
     looking at a medical record would need to know to treat that patient. The patient's history is a vital piece of
     information that enables physicians to determine the best diagnosis and treatment plan for that individual,
     based on information found in the medical record.

     Significance of Medical Documentation
2.             Medical documentation is essential for standards of care to be met. In many scenarios, like those
     in acute care hospitals, many different health professionals may see the same patient, but not necessarily
     together. Your nurse, doctor, lab personnel and other specialists are all involved in your care, and everyone
     needs to be kept up to date with what everyone else is doing. Without such coordination, your medical care
     would suffer.

     Medical Billing and Coding
3.              Without adequate medical documentation, your health care providers might not be reimbursed for
     providing you with care, leaving you stuck with the bill. There's an old saying in the health care industry:
     "If it's not documented, it didn't happen." That means that if one of your health care providers forgets to
     write something in your medical record regarding a treatment, surgery or procedure that you received, the
     facility will not be paid for it--and you'll most likely be sent the bill. Without adequate documentation that
     you received such services, how can you prove it happened? In addition, such errors also compromise
     patient safety and quality of service.

     Standards of Care
4.             Neglecting to document important details of a patient's visit to a doctor's office may have huge
     ramifications for physicians at a later date. For example, if a doctor or nurse fails to note that a patient is
     allergic to penicillin, and the health care provider later injects the patient with penicillin, causing a severe
     allergic reaction, the doctor may be charged with negligence. Other scenarios where physicians fail to
     carefully and correctly document medical data can result in medical malpractice suits. Standards of care
     require all health care personnel to follow guidelines that ensure best judgment for proposed treatments.
     Documentation is also a legal protection for both patient and physician or other health care provider that
     protect both parties in the event of a disagreement over care.

5.             Adequate medical documentation assures patient confidentiality and ensures that standards of care
     are being met. Doctors and other medical personnel have an obligation to treat illnesses to the best of their
     ability in regard to information documented in a patient's medical record. Failure to do so compromises
     medical ethics and professional conduct.
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