Importance of Quality Medical Record Documentation

Record keeping may not be the task that doctors and nurses wanted to tackle when they signed up for their positions, but attending to medical records is of vital importance. With well-kept medical records, medical professionals can keep tabs on patients and maintain all of the vital patient information at their fingertips.

Medical History

• It is vital that doctors and nurses are well-versed in a patient's medical history before they tend to the patient's current medical needs. In the absence of medical records, or if medical records are incomplete, these healthcare providers will not have a clear picture of the patient's past and, as a result, will not be able to properly deal with new medical issues.

Diagnostics

• Medical records play an important part in the diagnostics process. When doctors aim to determine what is wrong with a patient, they often review medical records. By inspecting the procedures that previous doctors have attempted or studying the patient's response to different medications the doctor can more adeptly determine the root of the patient's problem. If the records are not complete, the doctor may lack the information necessary to make informed guesses as to the causes of the patient's distress.

Communication

• When it comes to caring for a patient, rarely does just one medical professional tackle the task. Medical records that are up-to-date are highly useful in communication. When medical professionals keep up-to-date records, they allow others who may care for patients at other times during the day to easily determine what previous healthcare providers did and ensure that they don't overdose or otherwise improperly treat the patient.

Billing

• Though medical professionals may not personally tackle the task of billing, the records they keep are pivotal in ensuring that billing goes off without a hitch. These medical records are commonly shared with the billing department, telling them how much they must bill the patients and their insurance providers for. If these are errors in these medical records, billing may also be incorrect, leading to more hassle for both the patient and the billing department.