Documentation in the Medical Record
One of your professional obligations is to provide accurate and timely medical record documentation. The medical record verifies the care your organization provides. It also provides needed information to other healthcare professionals involved in the patient’s care. Providing certain information is also required for the organization to receive payment from patients’ insurance plans or from Medicare and Medicaid. For all these reasons and more, accurate documentation is essential for healthcare organizations.
Covered in this course:
- Identify the five purposes of medical record documentation
- State the advantages and drawbacks of handwritten, hybrid, and electronic medical/health record
- Use the dos and don’ts of charting to guide your documentation