What is Medical Documentation?
In the medical service industry, recording information about patients is the norm. It is done to keep track of all the services provided to the patient so that the healthcare providers readily know of the health status of the patients. Medical records are important for decision-making at a point of care.
All important information about patients such as history, changes in health status and all detailed diagnostic studies such as X-rays, MRIs etc and lab analysis reports are kept track of in the patient information records.
Medical records are not only vital for patient care but also for following the rules of the law. If records are not duly kept by any healthcare provider, it is considered to be a breach of law. Law understands it as “If it isn’t written down, you didn’t do it.” So all physicians are careful to get everything recorded meticulously so that they don’t face any legal problems.