posted on August 20, 2011 10:08
Proper and correct medical documentation
is pertinent for quality of medical care and health care services all over the medical field. From receiving treatment to receiving payment benefits from your health insurance provider, the documentation plays an important role.
Function of Medical Documentation
Without documentation, health care would be weakened. One doctor wouldn't know what another doctor was doing. Without accurate documentation of medical care including but not limited to visits, lab tests, treatments, or surgeries, quality of patient care would be diminished.
Medical documentation provides all information on a patient and their complete medical history. This allows medical professionals to interact with one another about one patient and all be on the same page mentally.
Significance of Medical Documentation
Medical documentation is essential for standards of care to be met. A lot of times, the same patient is seen in one facility several times but not by the same employees. Your nurse, doctor, lab person, and other specialists are all involved in your care, and everyone needs to be kept up to date with what everyone else is doing. Medical care would not be at its best without this.
Standards of Care
Failing to document important details of a patient's visit to a doctor's office may have insane consequences for physicians later on. If a doctor or nurse fails to note that a patient is allergic to a medication, and the health care provider later injects the patient with that medicine causing a severe allergic reaction, the doctor may be charged with negligence. Sometimes even lawsuits happen due to these kinds of mistakes.
Standards of care require all health care personnel to follow strict rules and guidelines that ensure best judgement for treatments. Medical documentation
is also a legal protection for both the patient and physician or other health care provider that protect both in the event of a disagreement over care.