Properly documenting patient’s medical records has always been important, reimbursement to the quality of the medical record.“Medical reimbursement is reflective of what you document, not just what you do,” We can take care of a patient with a wrist fracture, pneumonia, or a myocardial infarction, but if there is no documentation, there is no reimbursement.”For that reason and more, we encourages providers to “put thoughts to paper” and put good documentation practices into place.
Follow along with four reasons why it’s vital to properly document patients’ medical records.
1. Communicates with other health care personnel
2. Reduces risk management exposure
3. Records Hospital Quality Indicators and Measures
4. Ensures appropriate reimbursement
A well-documented medical record can facilitate effective revenue cycle processes, expedite payment, reduce any “hassles” associated with claims processing, and ensure appropriate reimbursement.Ninety-five percent of ensuring appropriate reimbursement is just good documentation practices that most our clinicians know.The other five percent consists of learning the rules provided by the federal government and other organizations that we need to know from a documentation compliance standpoint so that we are reimbursed correctly.
Other reasons why proper medical record documentation is important include:
- Tells the patient’s “story,” the presenting problem and the treatment received
- Helps to plan and evaluate a patient’s treatment
- Creates a permanent record for the patient’s future care
