April 19, 2011

If it Wasn’t Documented, it Wasn’t Done

The “wasn’t documented, wasn’t done” motto is a common one in healthcare settings, particularly as it applies to medical record documentation. Consistent and complete documentation in the medical record for every patient is an essential component of providing quality patient care.

This documentation is required to record pertinent facts, observations and findings, and must meet certain compliance standards. It is also an avenue of communication among healthcare providers in order to design the patient’s treatment plan over time.

The medical record continues to become increasingly important, and has become a tool to:

  • Track health care statistics
  • Act as a legal document
  • Justify to third party payers that charges billed were for medically necessary services

For these reasons and more, every healthcare professional should focus on accuracy and completeness in the patient’s medical record.

Healthcare professionals have an obligation to document appropriately and adequately to ensure standards of care are being met. Ways to stay current on accurate documentation standards can include the following:

  • Periodic re-training of staff
  • A compliance program that includes an audit plan

Ultimately, a well organized and well maintained medical record will provide a comprehensive source of information for staff, physicians, auditors and insurance payers. It is one source of past and present diagnosis and treatment. It is a history and a future plan for each patient at your fingertips. So, if that crucial information is not documented, for many patients, it really is just as if it wasn’t done at all.

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