Unfortunately, good documentation can become a low-priority for busy junior doctors. 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. The information in Dr. Ensure your organization’s documentation policies require providers to document: 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]. And the importance of complete, accurate, concise, timed and dated documentation cannot be overstated. Documentation plays so and integral part in any practitioner’s process, it would wise to maximize the usefulness of documentation. Documentation requirements vary by practice setting and by payer. Better documentation practices benefit everyone: better and more accurate delivery of healthcare, improvements in quality indicators, healthcare planning, reimbursement, and research. Have you ever considered the importance of patient documentation? 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.. Include proper medical record documentation for correct payment of your Medicare claims. In healthcare, usage, need and importance of code documentation and coding have increased significantly in the past decades. 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. Principles Of Documentation In Health Care Settings. The following key risk management strategies can help ensure adequate and appropriate documentation. Documentation Risk Tips. Since time immemorial, we have kept medical records as a vital document of understanding a patient’s health history. Clinical documentation improvement can play a critical role in the move toward value-based care, but healthcare organizations must take advantage of tools and … Documentation is so important in any treatment process; the lack of documentation not only may seem negligible but could quite possible be deemed negligible. Everyone is happy – doctors, nurses, coders, providers, insurers, regulatory agencies, and researchers. Because of documentation's essential role in healthcare, following best practices and standards is crucial. The quality of medical documentation has several far-reaching impacts, from directly affecting the quality of patient care, to influencing hospital funding. The HMOs, accreditation boards and government offices now call for maximum quality at minimum cost. 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. If you are a medical professional or run a medical practice, you know the importance of properly preparing medical records. 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. 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. 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