Top 4 Reasons Why You Must Prioritize Medical Documentation

By on November 11, 2019
Medical Documentation

Correct medical documentation for women over 50 is a vital task of all healthcare team members. It was essential in the past, is essential in the present, and will always be a must in the future, even with the advent of high-tech medical machinery and gadgets. 

Here are four reasons why you, as a medical provider, need to make sure that you prioritize all of your patients’ medical documentation.

Documentation is the main communication with other members of the healthcare team.

Documentation lets you communicate with all members of the healthcare team to treat and care for your patients. It fulfills the goal of making a continuous process of patient care and treatment, from doctors, nurses, assistants, technicians, and the rest of the team.

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Documentation lowers the risk of medical errors and malpractice.

Documentation decreases the risk of medical errors and malpractice. A medical error happens when there are inaccurate diagnosis and treatment of the patient. Medical malpractice is a legal case. It happens when a member of the healthcare team veers away from the standards of his or her profession. 

A properly documented patient record helps remove the liability claims of the medical team in case of a dispute. You can seek help from the experts at Healthcare Fraud Group LLC to know more about this topic. 

Documentation helps keep track of the facility’s quality and assurance measures.

Correct documentation assists in capturing an objective basis that measures the facility’s quality assurance (QA). It indicates whether the facility observes and practices the government’s rules and standards of good healthcare. It permits the QA team to compute the parameters. Also, it aids the QA team in building an action plan to make improvements in the future.

Documentation allows patients to apply for hassle-free reimbursement.

A correctly-documented medical record permits efficient reimbursement applications and fast payment processes. It also helps the patients to decrease the possibility of problems and concerns related to their claims. 

Remember that the approval of a medical reimbursement claim reflects if the healthcare team made effective documentation or not. For example, a patient suffers from a fracture, an infection, or a heart attack. If there is no documentation, then the patient cannot file for any claim, and whatever he shelled out to pay for his medical expenses cannot be reimbursed.

Additional Tips

Aside from the top four reasons above, here are minor factors to consider as to why medical documentation is a must.

  • The documentation gives the whole picture of the patient’s actual medical condition. It provides information from the presenting problem, the treatment done, and the reaction of the patient on the treatment.
  • It aids the healthcare team in planning and evaluating all the treatments done to the patient.
  • It becomes a basis for the patient’s future healthcare needs.

What information do you need to include in documentation?

Medical DocumentationWhile all presenting signs, symptoms, test results, plus the treatment done to the patient need to be in the patient’s record, here are some of the possible elements that you may also need to include in your documentation:

  • Name of the patient
  • Location
  • Severity 
  • Duration 
  • Timing
  • Context
  • Modifying factors

Correct medical documentation aims to give clear, concise, and accurate information for better patient care. With it, you can make sure that the patient receives proper per care and treatment. It also permits the patient to apply for reimbursement or claim for the expenses incurred for his or her medical condition if something goes wrong. 

However, if you get into trouble related to medical documentation, feel free to talk to any of the expert lawyers at Healthcare Fraud Group LLC. They will be glad to assist you throughout the process. Therefore, keep in mind that it should be one of the priorities of every healthcare team member. 

Darshan Shah is a young entrepreneur, digital marketer, and blogger. He’s the founder of The Web Reach and providing Digital Marketing services like SEO, Guest Blogging, Inbound Marketing and many more. He loves to help people to grow their business worldwide through his digital marketing knowledge.  He’s enthusiastic about creating blogs and writes creative content for the readers.


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Top 4 Reasons Why You Must Prioritize Medical Documentation