What Is Patient Documentation?

Why is patient documentation important?

Proper documentation, both in patients’ medical records and in claims, is important for three main reasons: to protect the programs, to protect your patients, and to protect you the provider.

Complete and accurate medical recordkeeping can help ensure that your patients get the right care at the right time..

What is the role of a clinical documentation specialist?

A clinical documentation specialist (CDS) organizes the information for each patient seen by a medical establishment. … A CDS handles this by reviewing medical records, ensuring medical codes have been inputted correctly, and documenting the specifics necessary to provide a full analysis of a patient’s health.

What is patient record documentation?

A patient’s medical record is the historical account of the patient/provider encounter and serves as a legal document for use in legal proceedings. Good healthcare decision making is dependent upon a provider’s ability to retrieve accurate and complete facts from the patient’s record.

What are the basic documentation principles?

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  • Document date and time of each recording.

    What is another word for documentation?

    Synonyms & Antonyms of documentationattestation,confirmation,corroboration,evidence,proof,substantiation,testament,testimonial,More items…

    What are five characteristics of good medical documentation?

    6 Key Attributes of a Medical RecordAccuracy of the medical record. The accuracy of the data refers to the correctness of the data collected. … Accessibility of the medical record. … Comprehensiveness of data. … Consistency of information in the medical record. … Timeliness of information. … Relevancy of the medical records.

    What are the steps in the medical documentation?

    Just in case you are not sure whether your practice has everything under control, here are the six key steps of a successful medical billing process:Patient Check-in. … Insurance Eligibility and Verification. … Medical Coding of Diagnosis, Procedures and Modifiers. … Charge Entry. … Claims Submission. … Payment Posting.

    What is the CDI process?

    CDI (Clinical Documentation Improvement) has been described as the process of improving healthcare records to ensure improved patient outcomes, data quality, and accurate reimbursement. … Clinically, it results in a more useful medical record and more meaningful patient information and data.

    What is clinical documentation?

    A clinical document (CD) is a written, printed or electronic record that provides evidence of medical care. … The standard, which is known as the Clinical Document Architecture (CDA), defines the structure of many common clinical documents such as admission or discharge records.

    What do you mean documentation?

    Documentation is a set of documents provided on paper, or online, or on digital or analog media, such as audio tape or CDs. Examples are user guides, white papers, on-line help, quick-reference guides. … Documentation is often distributed via websites, software products, and other on-line applications.

    What is the purpose of documentation?

    The purpose of documentation is to: Describe the use, operation, maintenance, or design of software or hardware through the use of manuals, listings, diagrams, and other hard- or soft-copy written and graphic materials.

    What are Documentation Standards?

    Documentation process standards define the process used to produce documents (example here). This means that you set out the procedures involved in document development and the software tools used for document production. … Document process quality standards must be flexible and able to cope with all types of documents.

    What is the advantage of documentation?

    Benefits Of Documentation. Accurate and up to date documentation makes your components, applications, web services, schemas and databases easier to use and maintain, reducing support requirements whilst improving quality and productivity.

    What are the types of documentation?

    Types of documentation include:Requirements – Statements that identify attributes, capabilities, characteristics, or qualities of a system. … Architecture/Design – Overview of software. … Technical – Documentation of code, algorithms, interfaces, and APIs.More items…

    What is the purpose of clinical documentation?

    The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication. The primary purpose of clinical documentation is to facilitate excellent care for patients.