Yes, Good Documentation Matters In Healthcare

Documentation - You must have heard a lot about it, but is it that important? Do you need to document everything or are you just worrying too much for nothing? Well, good documentation is one of the key components of meeting the requirements of a good medical practice. The importance of accurate clinical documentation cannot be overemphasized. It goes beyond delivering safe patient care. Timely reimbursements are in fact tied to the quality of your medical records. Today, documentation is everything. It is the foundation of a patient's medical records and gives a full picture of the patient's health. To put it simply, it includes everything from what treatments they've had and what medications they can and not take, to their lifestyle habits and lab and imaging results. Hence, it is extremely important that physician practices put in the time, effort and resources to ensure that documentation practices meet high quality standards.

The benefits of keeping good medical records

1. Safe and high-quality patient care

Accurate documentation is critical to providing safe and quality care. A comprehensive record of care reduces any risk of treatment errors and greatly improves patient outcomes. Hence, maintaining precise and complete medical records is crucial as it ensures that patients receive the right care at the right time. And, ultimately that is what matters the most - high-quality care and desired outcomes.

2. Timely reimbursements

Like any other business, it is important that you are reimbursed for your services. Clear and concise documentation facilitates accurate coding, and accurate coding paves the way for the correct, on-time reimbursements. Inadequate documentation, say for example not documenting why certain tests were requested or done, can result in delayed, denied, or reduced reimbursements.

3. Continuum of care

Documentation gives a full picture of the care the patient received right from the time of admission to the time of discharge and even after. Good documentation helps to establish continuity of care across health care team members involved in patient care. Hence, thorough and accurate documentation is important to facilitate an effective continuum of care through clear communication.

4. Protects against liability and malpractice lawsuits

A well-documented medical record is the best defense a physician can have in the event of disagreement over care. It serves as evidence that the treatment was carried out and saves physicians from any future liability risks. Hence, documenting every bit of detail can lead to better patient outcomes and a lower risk of malpractice.

Importance of accurate and timely documentation

'Right time' along with 'right information' is increasingly valuable in the healthcare world. Documentation timeliness can be hugely instrumental in diagnosing any medical condition and providing timely care. Ideally, documentation should be done concurrently at the time of service or shortly thereafter. Medicare requires accurate documentation to be done at the point of service or as soon after the assessment/treatment as possible. It is the responsibility of every physician to comply with this requirement and complete documentation in a timely manner. The longer it takes to make such records, the less reliable they can become. Because, if timely documentation is not done it will be difficult for the physician to recall the specific details of the patient encounter a week after the service has been rendered. Failure to maintain timely medical documentation can lead to delays in providing care or even a misdiagnosis. One of the most common reasons for documentation not being timely is lack of time on the part of the physician to do detailed documentation all while seeing patients. It is best to take the help of virtual scribes who help you document patient encounters accurately and in real-time.

Medical scribes create accurate and thorough medical documentation

Clear, accurate and timely medical records support clinical decision-making and patient care. If you are on the lookout for creating accurate and thorough medical documentation you may consider the use of medical scribes. A medical scribe's core responsibility is to accurately and thoroughly document patient visits, as they are being performed by the physician. Being trained in medical documentation they can provide accurate, thorough, and efficient charting. Most importantly, as documentation happens in real-time medical scribes improve the quality and accuracy of documentation. Whereas time and memory constraints might prevent a physician from writing accurate and detailed patient notes. A study reports that use of medical scribes can significantly improve chart quality and accuracy, all while improving both physician and patient satisfaction.

If you are a physician and struggling to maintain accurate and up-to-date medical record documentation then you have come to the right place. We at Scribe4Me have a pool of highly trained, certified medical scribes who can help you complete all documentation accurately directly into your EHRs. This allows you to focus solely on patient care activities without having to worry about performing documentation. Sounds appealing? Get in touch with us today! Our scribe representative will walk you through the scribing process and how our scribes offer a number of amazing benefits in addition to accurate and detailed documentation at the point of care.