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Effective Medical Documentation Delivers Better Patient Care

December 3, 2015

Documentation_and_billing.jpgWhat happens when poor record keeping takes place in your medical practice? It leads to both internal and external reports being incorrect, and reviews and investigations will likely be completely failed when poor record keeping is an issue within your practice. Inconsistent nursing records combined with a failure to properly record discussions with patients and family is a recipe for poor patient care. 

According to a study conducted by the Nursing and Midwifery Council in 2010, there are several culprits behind poor documentation, including:

  • Inaccurate and/or inconsistent documentation
  • Inefficiencies in the use of documentation
  • Absence of governance in documentation development
  • Implementation and review
  • Duplication of effort for staff, patients, and caregivers
  • Lack of evidence-based documentation

There’s also the belief that the multipurpose nature of medical record keeping contributes to its difficulties. For instance, effective record keeping will explain the following:

  • Confirm the prescription of treatment/care
  • Give a narrative of care and any changing conditions that have/are taking place
  • Confirm what has taken place to ensure that the plan of care is being fulfilled 


    Effective care planning often requires the extensive interpret

When your office produces records that don’t clearly meet the three above mentioned goals, you have documentation issues that need to be addressed. Here’s a look at several documentation tips you can follow. And remember, proper documentation isn’t about making your medical personnel work harder. In fact, proper documentation will lighten workloads and still at the same time provide better patient care — it’s a win-win for everyone. ation of lab results. If you have a patient who is coming in for reasons related to having labs performed, why not simplify the entire process and have the labs performed well in advance of their appointment? Not only does this allow you time to read through their results, but it also improves the work flow within your office.

Changes in Medical Documentation with ICD-10 Coding

For example, take for instance that a patient is coming visiting your office for a follow up on his diabetes. You already know in advance that you’ll need lab results to provide him with any advice and treatment recommendations. Because of this, having the labs performed in advance will make both the documentation and interpretation of the results much simpler. Furthermore, being that you will have lab results in your hands during the next appointment, you’ll be better able to answer any questions that the patient might have; this greatly reduces the need for follow-up letters and phone calls, meaning you can spend more time on medical documentation.

Also important is that chart preparation takes place, meaning every patient’s chart should be reviewed and organized before the appointment takes place. This helps the appropriate medical staff to understand the charts — and charts will vary from one patient/condition to another. By becoming more familiar beforehand with the applicable charts, this greatly increases the chances that the charts will be filled out correctly during the office visit. 

To provide effective patient care, the entire patient must be treated. The only way to accomplish this goal is by properly documenting all vital data and sharing it — according to HIPAA guidelines — with the appropriate physicians and entities. As you progress in your career as a physician, you will undoubtedly learn how such programs, can augment the intra- and interdisciplinary communication processes, allowing you to deliver better care for your patients’ future needs. These programs facilitate a sharing of information in real time, keeping all relevant physicians up to date with the latest findings, which boosts patient care even further. 


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