Importance of Accurate Patient Documentation in Electronic Medical Records

May 2, 2012 — 3,194 views  
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Patient medical records are extremely important to a functioning health care practice. These documents contain a plethora of private information regarding how people were treated for certain ailments. They are beneficial to clinical communication and the planning of care, and also help evaluate the adequacy of care that has been given. Patient documentation must include various supporting files in order for the entire record to be complete.

Many doctors prefer Electronic Medical Records (EMRs) to gather information pertaining to specific patients. An EMR should include medical history, results of any examinations and final decisions pertaining to a course of treatment. The document serves as the reasoning behind why medical treatment was administered in a certain manner.

In many situations, EMRs are legal records that protect both the caregiver and the patient. If treatment is ineffective for whatever reason and the patient feels that more could have been done, the EMR offers insight into the doctor's train of thought and supports his or her conclusion. Conversely, if the doctor mismanaged information, the document would help a patient garner proper compensation for any misuse of resources on the part of the doctor. An EMR is essential for superior medical documentation and care.