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Why Quality Clinical Documentation Matters

March 18, 2022

Patients seek medical care hoping for a high-quality experience across the board. Offering a diagnosis, treatment plan, and path for the future are a few ways to ensure your patients get what they need. However, quality clinical documentation is also essential to give patients the best possible encounter.

What Is the Purpose of Medical Records?

Medical documentation often takes place behind the scenes, but excellent patient care is prioritized. Medical records that aren’t filled out wholly or accurately can impact patient care and cause miscommunication between practitioners. It can also result in revenue loss for your practice.

A medical record includes the basics, such as patient demographic information and required forms. However, it also contains the patient’s medical history and notes on how the patient is doing. A list of all the medications a patient takes will also be included and should be updated when anything changes. Complete documentation records will also have the results of medical testing and treatments.

A patient’s tests may not be ordered without a complete medical record. Medication that negatively interacts with something the patient is already taking may be prescribed. Improper documentation of notes and vitals can result in a misdiagnosis and cost a patient valuable time when they could be receiving treatment.

Patients already under the stress of illness shouldn’t have the added stress of trying to have errors in their clinical documentation corrected. You should have a system that prioritizes quality documentation from the start.

Why Is Documentation Important in Healthcare?

Medical documentation creates a trail showing where your patient started and where they have been on their journey. It should offer a comprehensive view of a patient’s care and experiences from diagnosis to treatment when done right.

It plays a critical role in medical decision-making and mitigates risk for the provider. Additionally, documentation ensures timely and accurate payments for medical services and the ability of medical providers to maintain continuous care for their patients.

Medical record documentation is passed to every practitioner who needs it to help a patient. An inaccurate or incomplete record can make a treatment plan tailored to a person’s needs impossible. When the practitioner isn’t aware that anything in the records is amiss, they will decide on false information.

What Else Is at Stake?

It’s not just patients who suffer when documentation records aren’t quality. Caregivers trying to secure the best care for their loved ones face an extra hurdle when necessary information is not recorded. Caring for a sick friend or family member already means an increased risk of anxiety, depression, and immune system dysfunction.

Medical records ensure the caregiver doesn’t have to remember all the information and relay it at every appointment. They should be able to walk in and know that the doctors and nurses at the clinic already have the essential information to help their loved ones make the right decisions.

Besides affecting care, mistakes in a medical record can affect a person’s ability to receive life or health insurance coverage. Disability insurance can even be impacted, and the stress of trying to have these errors corrected negatively impacts a patient’s mental health.

Medical record documentation also documents procedures that have already been tried and the result. They take pressure off the patient because accurate documentation means not having to fill out the same forms or answer the same questions at every visit. Plus, patients receiving treatments for chronic illnesses cannot be expected to remember everyone.

Quality clinical documentation is the foundation on which quality care is built and ensures a patient is genuinely seen before a diagnosis or treatment plan is offered.

At Nashville Oncology, we believe in treating the whole person, not just the disease. Quality documentation ensures we provide personalized care and treatment that meets the individual needs of our patients and their loved ones throughout their cancer journey.