Purpose of Medical Documentation

Medical documentation is the recording of patient information while under the care of a health care professional. Medical documentation, whether written in a paper-based medical record or entered into an electronic medical record, serves many purposes.

Documents Patient Care

• Medical documentation provides an accurate record of the patient's current diagnoses and treatments.

Facilitates Ongoing Patient Care

• Medical documentation provides a patient's medical history for ongoing care. Previous medical documentation is reviewed to gain a thorough understanding of how to provide ongoing care for a patient.

Provides for Billing and Reimbursement

• Diagnoses and procedures documented in a patient's record are used to bill insurance companies in order to receive reimbursement for care provided.

Fosters Research

• Medical documentation provides information for health care clinical research to promote better care. In addition, medical documentation is used to understand patient outcomes, assess technology needs and review costs.

Promotes Education

• Medical documentation is used to educate health care professionals. Documentation may be used as case study examples to provide conference, seminar and presentation materials for current health care professionals or students.

Assists in Regulation

• Medical documentation is a legal record and can be used as evidence in court. In addition, medical documentation can be used to insure organizational compliance and for accreditation of health care professionals.