Documentation plays so and integral part in any practitionerâs process, it would wise to maximize the usefulness of documentation. Have you ever considered the importance of patient documentation? Principles Of Documentation In Health Care Settings. Good documentation is an important part of improving both patient care and nursing practice. And the importance of complete, accurate, concise, timed and dated documentation cannot be overstated. Because of documentation's essential role in healthcare, following best practices and standards is crucial. Dr. Julie Taitsman, Chief Medical Officer for the Office of Inspector General, gave a presentation recently as a part of the OIGâs award-winning HealthCare Fraud Prevention and Enforcement Action Team (HEAT) on the importance of documentation for Medicare and Medicaid claims. The primary purpose of the documentation is to provide the physician with a record of a patient's history and other details that he or she might not otherwise remember between visits. In healthcare, over the past 25-30 years weâve seen the use, need, and importance of clinical documentation and coding greatly increase. Unfortunately, good documentation can become a low-priority for busy junior doctors. The quality of medical documentation has several far-reaching impacts, from directly affecting the quality of patient care, to influencing hospital funding. Whether it is for treatment or procedures, inpatient or ambulatory, or private, public, or government payers, it doesnât matter as the value is still there. The information in Dr. In healthcare, usage, need and importance of code documentation and coding have increased significantly in the past decades. Proper documentation promotes safe patient care, good communication among staff members, and the advancement of the nursing profession. Include proper medical record documentation for correct payment of your Medicare claims. The HMOs, accreditation boards and government offices now call for maximum quality at minimum cost. The healthcare industry needs to meet the desired standards of quality and accuracy in documentation and therefore there is an increasing demand of medical transcription day by day. Documentation Risk Tips. If you are a medical professional or run a medical practice, you know the importance of properly preparing medical records. The following key risk management strategies can help ensure adequate and appropriate documentation. Ensure your organizationâs documentation policies require providers to document: Documentation requirements vary by practice setting and by payer. Documentation is so important in any treatment process; the lack of documentation not only may seem negligible but could quite possible be deemed negligible. Everyone is happy â doctors, nurses, coders, providers, insurers, regulatory agencies, and researchers. In a recent Student BMJ article, the author explains that "the patient's narrative gives important clues as to the diagnosis and the patient's perspectiveâ¦" [4]. Watch a brief video on the Importance of Documentation from the Office of the Inspector General (OIG) to learn how proper documentation protects the provider, patient, and Medicare program integrity.. Documentation plays a critical role in communicating to third-party payers the need for evaluation and treatment services (medical necessity) and why those services require the skill of the speech-language pathologist (SLP). 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