IMPORTANCE OF DOCUMENTATION

Good medical documentation promotes patients' and physicians' best interests for different
reasons. Recording all relevant information of a patient's care helps practitioners monitor what's been
done, and minimizes the risk of errors creeping into the treatment process. Careful attention to detail also
reduces the likelihood of patients returning for additional treatment. The process also demands a high
degree of self-evaluation that's essential to promoting good clinical practices, as well as a practitioner's
professional development.

Basic Documentation
Good medical records document basic facts of patient care, including what was done by whom, and what
results occurred, according to an outline from the New York State Society for Clinical Work, Inc. Compiling
meaningful clinical details in one place supplements the medical practitioner's memory of crucial events
that occur later in treatment. Accurately recording all complaints and symptoms also helps other
practitioners caring for the patient to identify trends, while guiding them in the development of treatment
plans.

Improved Outcomes
Keeping proper records improves patients' clinical outcomes once they leave the hospital, according to a
November 2006 report by the Ontario Ministry of Health and Long-term Care. About 20 percent of patients
experience adverse events after discharge, including drug reactions, infections and procedural
complications. Many of these problems result from delayed or incomplete information given to subsequent
health care providers. The ministry's report also cited a 2003 study that found patients with significant
gaps in their health records spent an average of 1.2 hours longer in emergency rooms.

Malpractice Defense
Proper documentation is the best defense against a malpractice claim, Dr. Jeff Greenberg writes in a
commentary for UCLA's Department of Medicine. For judges and juries, if a procedure doesn't appear on
a chart, it hasn't been done. Physicians must ensure that all X-rays and other lab work are done, and
follow up with the patient. This step minimizes the risk of a missed diagnosis. Good record keeping is also
vital in dealing with patients who are abusive, don't follow advice, or present the same complaint without
improvement.

Quality Assurance
Sound record keeping also plays a role in quality assurance practices. According to the society's outline,
writing accurate initial assessments and progress notes improves patient care by requiring medical
professionals to think carefully about what they do. Over time, practitioners develop a capacity for selfreflection that's vital to professional development, maintaining professional skills, and continuing to
provide high quality clinical care. Members of a treatment team can also learn from each other, and
coordinate their approaches, which also serves to improve the quality of patient care.

Reference:
Heibutzki, R. Importance of Medical Documentation. Retreived July 29, 2015, from
http://work.chron.com/importance-medical-documentation-6966.html

REACTION:
As a health care provider, one of the most important things to do is document. You
document the patients history, complaints, findings on examinations, and diagnoses. You keep
a record of a patients current medications and allergies. You record the time spent with a
patient and the directions or instructions given to the patient.
Good documentation is in the patients best interest; it facilitates thorough and accurate
health care and protects the clients from other risks. Proper documentation may also protect a
health care provider from liability should an issue arise regarding the care provided to a
particular patient.
In the context of medical malpractice litigation, documentation is of vital importance and
can make or break a health care providers defense. One problem that is often encountered in
medical malpractice litigation is poorly kept or confusing medical records.
Remember that care that is not documented is care that is not given at all. The chances
of one being out of the job as a health risk provider is great. A well-documented chart can serve
as an independent witness to the care provided.
Practitioners, medical practices, health care providers, and hospitals alike should have
clear record keeping policies, and health care providers should be vigilant in their daily record
keeping practices for the patients sake as well as to avoid any potential issues should a lawsuit
subsequently arise.