Medical Record Documentation : Medical record documentation is the process of creating and maintaining accurate and complete medical records. It is a critical part of providing quality patient care and is essential to the success of any healthcare organization. There are some general guidelines that apply to all states. First and foremost, medical records must be accurate and complete. They must also be legible, organized, and easily accessible. In addition, medical records must be maintained in a confidential manner and must be protected from unauthorized access (Saravi et al., 2016). There are a few ways to document medical records. The most common way is to use an electronic health record (EHR). This is a digital record of a patient’s health information that is created and maintained by the provider (Guo et al., 2017). EHRs can include everything from a patient’s demographics and medical history to their current medications and lab results. Another way to document medical records is to use a paper chart. This is a physical record of a patient’s health information that is kept on site at the provider’s office. Paper charts can be less convenient than EHRs, but they may be easier to access in some situations. Medical records can also be stored in a central database, such as the National Health Service’s Spine. This is a secure, online system that stores patient health information and makes it available to authorized health care providers. The medical record is a legal document that becomes the property of the healthcare facility where the patient is seen. The medical record is the source document for coding the patient’s diagnosis and procedures. The medical record is used to support the physician’s decision-making and to help guide care. The medical record documents the patient’s response to treatment and can be used in medico-legal cases. There have been many technologic developments and improvements in medical record documentation in recent years. One major development has been the adoption of electronic health records (EHRs). EHRs can improve the accuracy and completeness of medical record documentation, as well as make it easier to access and share information. Other technologic developments include the use of natural language processing to automatically extract information from medical records, as well as the use of artificial intelligence to improve the efficiency of medical record documentation.
Accessing this course requires a login. Please enter your credentials below!