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.
Timeliness

There are specific requirements for completion of the medical record:

History and Physical – completed and signed within 24 hours of admission
Post-Operative Note – written immediately following surgery.
Operative Note – dictated and signed within 24 hours of operation/procedure
Medical Record – must be completed within 7 days of discharge or outpatient visit.
Confidentiality

Medical records are confidential and protected by authority of the Privacy Act of 1974, its amendment and HIPAA
Don’t leave patient-identifiable information on your computer screen or exposed in your work area.
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
encounter
Appropriate history and physical exam in relationship to the patient’s chief complaint;
Review of labs, x-ray data and other ancillary services, where appropriate;
Assessment; and
Plan for care (including discharge plan, if appropriate)
- Past and present diagnosis should be accessible to the treating and/or consulting physician

The reason for – and results of – x-rays, labs and other ancillary services should be documented and included in the medical record.
Relevant health risk factors should be identified.
The patient’s progress, including response to treatment, change in treatment, change in diagnosis, and patient non-compliance, should be documented
The written plan for care should include, when appropriate:
Treatment and medications, specifying frequency and dosage;
Any referrals and consultations;
Patient/family education; and
Specific instructions for follow up
The documentation should support the intensity of the patient evaluation and/or the treatment, including thought processes and the complexity of the medical decision-making as it relates to the patient’s chief complaint for the encounter.
All entries to the medical record should be dated and authenticated
The CPT/ICD-10-CM codes reported on the CMS-1500 claim form should reflect the documentation in the medical record.