Importance of Accurate Medical Documentation in Healthcare

Clinical Documentation

The Importance of Proper Medical Documentation Medical documentation is a form of communication within the medical record; It promotes continuity of care through clear communication between all members involved in patient care(How to document medical information P2) Medical documentation is a legal document; In any legal proceeding, documentation is heavily scrutinized to help support an argument. Documenting sensitive discussions regarding limits of care, prognosis, and treatment decisions clearly and transparently is crucial(How to document medical information P2) Medical documentation is a document of service; Thorough documentation of all medical issues and treatments is crucial for hospital funding and discharge summaries(How to document medical information P2)

Complete & Accurate Physician Documentation Documentation should be reviewed and validated at the time of entry(Evolving Roles in Clinical Documentation P2) Documentation should always be clear, concise, and to the highest level of specificity, In order to paint the most accurate clinical picture(Evolving Roles in Clinical Documentation P2) Report a complete list of diagnosis that captures all the conditions that warranted the encounter(Evolving Roles in Clinical Documentation P7) Capture all diagnosis that are relevant to the treatment, socioeconomic, and/or psychosocial circumstances are important to capture the patient s clinical picture and potential health hazards(Evolving Roles in Clinical Documentation P8)

Patient records 410296 & 410092 INCOMPLETE INCOMPLETE DOCUMENTATION DOCUMENTATION Record 410296 is not clear and concise and does not paint an accurate clinical picture. Was the full-thichness soft tissue flap that was on the labial aspect performed on teeth 6 to 9 or teeth 6,7,8, and 9 Exactly which tooth was the surgical endodontic therapy completed on Which tooth was the retentive prep performed on What is the postoperative diagnosis ACCURATE DOCUMENTATION ACCURATE DOCUMENTATION Record 410092 shows supporting documentation for diagnosis and procedure, with imaging and lab results; It is clear, concise and paints an accurate picture of the patient's diagnosis

Records 410057 & 410198 INCOMPLETE INCOMPLETE DOCUMENTATION DOCUMENTATION ACCURATE DOCUMENTATION ACCURATE DOCUMENTATION Record 410198 completely documents the chief complaint, past medical history, family history, social history, Review of systems. This record covers the entire SOAP note. Record 410057 does not specify exactly what procedure (mastectomy, biopsy or the breast reconstruction) was completed. Were all three procedures completed during the same surgery

REFERENCES Practice Brief: Evolving Roles in Clinical Documentation Integrity: A Practice Brief: Evolving Roles in Clinical Documentation Integrity: A Provider s Guide to the Art of Provider s Guide to the Art of Documentationhttps://journal.ahima.org/practice Documentationhttps://journal.ahima.org/practice- -brief roles roles- -in in- -clinical clinical- -documentation documentation- -integrity integrity- -a a- -providers art art- -of of- -documentation/ documentation/ How To Document Well, Sara How To Document Well, Sara Syed,https Syed,https://onthewards.org/how document document- -well/ well/ brief- -evolving evolving- - providers- -guide guide- -to to- -the the- - ://onthewards.org/how- -to to- -