Consequences of Incomplete Patient Documentation

April 20, 2012 — 3,140 views  
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Patient documentation is an essential part of medical care. Paperwork is used to compile information on a certain person, the treatment he or she received and personal information for billing and other necessary purposes. While filing the proper paperwork may seem easy to overlook, the consequences of incomplete patient documentation are vast. In fact, a practicing doctor can lose his or her license by forgetting to note a certain discussion.

In many ways, an incomplete medical record demonstrates that care was improperly administered, and can be used to support allegations of negligence and fraud. As a result of poor paperwork management, a doctor can cause a loss in revenue at his or her practice, lead to inappropriate billing, interfere with patient-related studies and result in costly treatment methods.

Doctors need to pay close attention to how medical paperwork is filled out, because the documents are an important and necessary part of the overall health care process. If a patient is unsatisfied with the result of certain treatments, patient documentation may serve as a doctor's defense, as the forms often outline the care that is to be administered and require a patient's signature.