The documentation captured during an encounter becomes part of the patient’s legal medical record. As healthcare providers, we believe one of the medical record’s most critical functions is to plan and provide continuity of care for a patient’s medical treatment.
Healthcare providers need to also remember the additional functions of the medical record, including the following:
- providing information for the financial reimbursement to hospitals, healthcare providers and other sites of service, and patients;
- providing legal documentation in cases of injury or other legal proceedings;
- providing information for quality improvement/assurance and peer-review committees, state licensing agencies, and state regulatory agencies when assessing the quality of care provided; and
- providing the critical information in an accreditation process.
The final, legal medical health record is ultimately defined by your organization. Assessing and defining the medical record for complete documentation elements are imperative. Ultimately, auditing documentation to assess the completeness of a medical record, determining the accuracy of documentation, and potentially discovering lost revenues should be a part of your clinical and operational process.
Read the rest of the article at Advances in Skin & Wound Care.
An excerpt from an article originally published in Advances in Skin & Wound Care, written by Cathy Thomas Hess, BSN, RN, CWOCN, VP and Chief Clinical Officer at Net Health
