Medical Documentation: How it Can Minimize Malpractice

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You may know that doctors are highly regarded in several regions but, it just takes a minor hiccup or two in how you run your office, to flip this image. Treatment or diagnoses can certainly lead to negative outcomes if it is not done thoroughly and properly, this includes medical documentation.

On the other hand, while patients want thorough examinations, they also wish to interact with the doctor, receive and make eye contact, and have an overall connection with their provider. There are several factors that work behind this fine balance, and for that many reasons, you cannot sacrifice quality medical documentation in your practice.

What is Medical Documentation

This is a kind of analog or digital record that consists of all the details regarding treatment, clinical tests, and any health service specifically given to the patient. Like a mark sheet that shows your academic qualification, medical documentation also records all the relevant information of your health.

Importance of Well-documented Medical Documentation and How it Mitigates Malpractice

  • Diminish Malpractice

Excellent documentation provides the ultimate clinical assistance to the doctor, therefore, diminishes the risk of malpractice. Dr. Jeff Greenberg, a renowned orthopedic surgeon believes that proper medical documentation is the ultimate defense against any malpractice claim. When a patient goes to a doctor, the record of that patient helps the doctor to diagnose them properly. 

  • Medium of Communication

Medical documentation plays the role of a medium through which you can communicate with other medical personnel, as a result, it lets them know the clinical care that you’ve provided. This includes history collected on the patient.

  • Promotes Reimbursement

A well-documented medical record assures proper reimbursement. Along with it, it is capable of facilitating revenue cycle processes effectively and it can also expedite the payment process. Moreover, it can minimize any sort of hassles related to claims processing.

  • Tells the Story of the Patient

A well-written story can make you understand all the important characteristics of the protagonist. Similarly, a well-documented medical record tells the story of a patient in detail. Here, the story refers to the existing problems and the treatments the patient has received.

  • Supports Proper Treatment Plan

Without a proper plan, a doctor cannot go further. Proper medical documentation is the only thing that can help doctors do this.

  • Record for Future Care

The way patients will be treated in the future is inextricably related to the patient record and if there is no well-documented chart, the future care of the patient will be deeply affected.

For help with thorough medical documentation, visit My Virtual Scribe today.

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