Question: Why Is Patient Documentation So Important To The Medical Record?

What is the purpose of medical records?

The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient’s care..

Why is patient documentation important?

Proper documentation, both in patients’ medical records and in claims, is important for three main reasons: to protect the programs, to protect your patients, and to protect you the provider. … Complete and accurate medical recordkeeping can help ensure that your patients get the right care at the right time.

What should be documented in a patient’s medical record?

What is a medical chart? A medical chart is a complete record of a patient’s key clinical data and medical history, such as demographics, vital signs, diagnoses, medications, treatment plans, progress notes, problems, immunization dates, allergies, radiology images, and laboratory and test results.

What is the purpose of documentation?

The purpose of documentation is to: Describe the use, operation, maintenance, or design of software or hardware through the use of manuals, listings, diagrams, and other hard- or soft-copy written and graphic materials.

What are the three main steps to coding accurately?

Here are three steps to ensure you select the proper ICD-10 codes:Step 1: Find the condition in the alphabetic index. Begin the process by looking for the main term in the alphabetic index. … Step 2: Verify the code and identify the highest specificity. … Step 3: Review the chapter-specific coding guidelines.

What are some examples of poor documentation practices in patient records?

According to several HIM experts, the top four documentation mistakes are:Mixed messages from a physician vis á vis misunderstood dictation or illegible handwriting.Misuse of copy and paste or copy forward functions in the electronic health record (EHR)Incomplete or missing documentation.Misplaced documentation.

What are the two types of medical records?

There are two different documentation formats that are used for medical records, the source-oriented medical record and the problem-oriented medical record. The more traditional format used for recording data in the medical record is the source-oriented medical record (SOMR).

Why is documentation important in medical coding?

Most importantly, accurate documentation can lead to better, more effective patient care. It can provide more detailed information to other health care providers performing subsequent care or services on patients. Documentation in the patient’s record will be integral to accurate coding with the new system.

What are five characteristics of good medical documentation?

6 Key Attributes of a Medical RecordAccuracy of the medical record. The accuracy of the data refers to the correctness of the data collected. … Accessibility of the medical record. … Comprehensiveness of data. … Consistency of information in the medical record. … Timeliness of information. … Relevancy of the medical records.

Why clinical documentation improvement is so important to hospitals?

Clinical documentation improvement (CDI) helps ensure that the events of the patient encounter are captured accurately and the electronic health record properly reflects the services that were provided. … CDI also ensures that all members of the care team receive information on a patient, AHIMA added.

What is proper documentation?

Proper documentation provides evidence of what has transpired as well as provides information for researching discrepancies. Supporting documentation may come in paper or electronic form. In recent years, more often, official supporting documentation has moved from paper based to electronic forms.