The safety and quality of care provided in Australia’s health system is of utmost importance to all patients, their families, and carers. A safe and high-quality health system provides the most appropriate and best-value care, while keeping patients safe from preventable harm in the delivery of care.
Major advances are frequent in the arenas of diagnostic testing, therapeutics, and pharmaceuticals. Modern information transfer technology has made physicians’ ability to access information about these advances easier and contributed to patients being more aware of changes in many aspects of health care. At the same time, physicians may be called on to limit utilization of health care resources to services that are judged to be “medically necessary.”
Yet both as a contribution to health care costs and as a key element in patient-doctor relationships, there is reason to believe that it deserves more attention. Furthermore, with an increasing emphasis on value and efficiency in health care delivery, quality time between physician and patient is an increasingly valuable resource. Physicians spend time in face-to-face contact with patients gathering information, and developing a relationship, doing administrative work related to visits, and maintaining their knowledge base. Importantly, time is always finite: no matter what demands a physician faces, there are only 24 hours in a day.
In the current practice environment, physicians face mounting demands on their time. Increasing administrative requirements for health care delivery (e.g., service and authorization requests, utilization review processes) encroach on time spent with patients.
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
