Information on Medical Documentation

Doctors and medical staff document the treatment they provide for every patient who is seen. The information found on medical documentation is pertinent not only to the patient's medical chart, but also allows insurance claims examiners to determine how much to pay doctors for their medical services.

Features

• Medical documentation must contain the patient's name and the date that the service was provided. A summary of the patient's symptoms, vitals and the doctor's observations of the patient must also make it into the documentation. A diagnosis is provided, as well as a special code that signifies what type of service was provided.

Privacy

• The information that ends up on medical documentation is confidential and protected by HIPAA, the U.S. Health Insurance Portability and Accountability Act. It is a federal offense to misuse or disclose patient documentation without the authority from the patient to release their information to another entity. Medical documentation is housed in medical charts that are either in hard form or electronic.

Warning

• Medical documentation must accurately describe the patient's session with the doctor. Documentation containing false or inaccurate information about services that were provided is considered fraud, and can result in financial penalties, the loss of a medical license and practice, or jail time.