Essay On Medical Documentation

Identify the steps in the medical documentation process.

Accuracy

Each patient’s medical record must be correctly documented.
Information in the medical record is relied upon for complete accuracy throughout the patient’s lifetime.
Inaccuracies (either commission or omission) lead to improper medical advise being provided in error and may result in adverse healthcare outcomes or in legal proceedings.
Relevance

It is important that medical records contain only information relevant to the patient’s healthcare.
Inclusion of inappropriate and irrelevant information could result in damaging legal action.
Completeness

All documentation, including that from clinics and hospitals, must be included in the medical record.
Every document should be free from omissions.
Shred papers containing patient information that is not relevant to medical documentation.
Don’t talk about patients or families in hallways, elevators, or in other public places.
Don’t release medical record information without the patient’s consent.
Explain why medical documentation is required.

Good medical documentation protects physicians and other health professionals against claims of negligence. Seemingly innocent omissions in medical records can have devastating consequences for a patient. Medical records often are the most important objective evidence physicians and hospitals can offer in their defense against a malpractice claim. Poor medical records make it difficult to determine whether an adverse outcome resulted from factors beyond the physician’s control or from negligent medical care.

List the principles of documentation.

The medical record should be complete and legible
The documentation of each patient encounter should include:
The date
The reason for the