importance of documentation in healthcare

In a recent Student BMJ article, the author explains that "the patient's narrative gives important clues as to the diagnosis and the patient's perspective…" [4]. The healthcare industry needs to meet the desired standards of quality and accuracy in documentation and therefore there is an increasing demand of medical transcription day by day. Good documentation is an important part of improving both patient care and nursing practice. To find out more about the specific documentation standards where you practice, contact your state board of nursing. Proper documentation promotes safe patient care, good communication among staff members, and the advancement of the nursing profession. The primary purpose of the documentation is to provide the physician with a record of a patient's history and other details that he or she might not otherwise remember between visits. Ensure your organization’s documentation policies require providers to document: It doesn’t matter if it’s for diagnoses or procedures, inpatient or outpatient, or private, public, or government payers – the importance is still there. Dr. Julie Taitsman, Chief Medical Officer for the Office of Inspector General, gave a presentation recently as a part of the OIG’s award-winning HealthCare Fraud Prevention and Enforcement Action Team (HEAT) on the importance of documentation for Medicare and Medicaid claims. Include proper medical record documentation for correct payment of your Medicare claims. Better documentation practices benefit everyone: better and more accurate delivery of healthcare, improvements in quality indicators, healthcare planning, reimbursement, and research. The information in Dr. Documentation plays a critical role in communicating to third-party payers the need for evaluation and treatment services (medical necessity) and why those services require the skill of the speech-language pathologist (SLP). Documentation plays so and integral part in any practitioner’s process, it would wise to maximize the usefulness of documentation. Clinical documentation improvement can play a critical role in the move toward value-based care, but healthcare organizations must take advantage of tools and … Have you ever considered the importance of patient documentation? Documentation Risk Tips. Whether it is for treatment or procedures, inpatient or ambulatory, or private, public, or government payers, it doesn’t matter as the value is still there. In healthcare, over the past 25-30 years we’ve seen the use, need, and importance of clinical documentation and coding greatly increase. Since time immemorial, we have kept medical records as a vital document of understanding a patient’s health history. Unfortunately, good documentation can become a low-priority for busy junior doctors. The quality of medical documentation has several far-reaching impacts, from directly affecting the quality of patient care, to influencing hospital funding. Documentation requirements vary by practice setting and by payer. Principles Of Documentation In Health Care Settings. The HMOs, accreditation boards and government offices now call for maximum quality at minimum cost. And the importance of complete, accurate, concise, timed and dated documentation cannot be overstated. Watch a brief video on the Importance of Documentation from the Office of the Inspector General (OIG) to learn how proper documentation protects the provider, patient, and Medicare program integrity.. In healthcare, usage, need and importance of code documentation and coding have increased significantly in the past decades. Because of documentation's essential role in healthcare, following best practices and standards is crucial. The following key risk management strategies can help ensure adequate and appropriate documentation. Everyone is happy – doctors, nurses, coders, providers, insurers, regulatory agencies, and researchers. Documentation is so important in any treatment process; the lack of documentation not only may seem negligible but could quite possible be deemed negligible. If you are a medical professional or run a medical practice, you know the importance of properly preparing medical records.

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