Patient care is at the core of practicing medicine for every medical expert out there. Today, when data about patients can be stored and preserved better than ever preserving its integrity is becoming more important than ever. Clinical documentation has been important since the early days of medicine. Having your detailed report of medical history serves you not today, but also in the future, and it can be useful to your offspring. if your record is not what it’s supposed to be it can have an adverse effect on your treatments and future diagnosis.
This is why care of your documents must be conducted in a timely and careful manner. It all starts with the employees in a hospital where you’re admitted or from your local doctor. When data about you is collected there’s no space to avoid or miss anything. Inadequate documentation is essential for your well-being. This is why we’re going to talk about it in length today. If you’re not aware of the ramifications that not taking care of this issue could have, please read our three reasons why clinical documentation integrity is so important. Before we start, let’s see what is clinical documentation.
What is Clinical Documentation
As the title says, we’re talking about a set of documents that intend to record your medical treatment, or in some cases to store files about a clinical trial you underwent. It can be recorded digitally but there’s also an analog record available. The focus of these documents needs to be precise. Every file needs to contain data about the patient and the care provided to him and in which order. Accuracy is what matters in these instances the most. When it comes to medical records, it doesn’t contain only the process of your medical treatment but also doctor’s notes, X-rays, MRIs, and any other data vital for your treatment. Its goal should be clear to understand to every patient and health provider alike.
Access to it needs to be allowed to doctors and the staff in the hospital when it comes to communicating with the patient, but it holds an even deeper legal value. The track record of a patient’s treatments can be revisited if a need arise. These are seen as legal records and can be used by public health agencies and authorities of law when there’s research needed of the treatment that a patient underwent. Furthermore, it is a quite useful data collection when it comes to the creation of a patient’s longitudinal records which contain all the available info of a patient’s healthcare throughout his medical history.
In most cases the first time that anyone reaches for clinical documentation once the patient has completed his treatment is in a case there’s an upcoming claim. To avoid any possible mistakes that could happen with these documents many healthcare providers hire a specialist in the domain of clinical documents which focuses on improving their quality. Sometimes it is needed to handle these papers the right way, to make them fully comprehensible to anyone who needs to access them.
Sometimes, even if everything is done the right way regarding the patient, and no harm was done, a claim could cause issues if the clinical documentation isn’t handled the proper way. In cases like this, it is easy to prove that the integrity of clinical documents is lacking even though the healthcare provider did the job without any issues. But, technicalities matter in court, so it is vital to hold onto the integrity and the proper way all documentation needs to be sorted and preserved. Now, let’s see why it’s so important.
1. To Better Communicate
At this point, we’re no longer speaking about direct communication. It’s all about what your documentation has to say for itself. Clinical care is vital when you’re in a dire situation and the records that are left behind serve the purpose of showing why, how, and what occurred to the patient. It’s essential to have them tracked down through your medical history. Later on, they’re used to better judge the patient’s history to provide better treatments for repeated conditions and any new that could arise. When a patient is in a serious pinch, looking through their clinical documentation can provide the doctors with answers that can be concluded from the current condition of the patient.
2. To Improve The Standard of Care
Standard of care matters. Not only because it’s vital to take good care of patients, but because if it is not handled the right way, a patient can have legal issues with the hospital or his doctor. If a patient’s clinical documentation is handled the right way, and it holds integrity it serves the purpose of protecting a patient. So, if it is not abided the right way the legal weapons will be in the hands of the patient. Healthcare providers are in danger of breaching the standard of care if they don’t conduct themselves the right way. So, a patient whose records are handled the right way almost guarantees the safest treatment for himself. If you want your files to be in the right hand and guarded the right way, you should also for help in hand from Pinson & Tang who excel in this domain.
3. Reduced Risk Management
Having accurate documentation is vital for both the patient and the organization providing health care. If everything is in order the risk that a successful claim against malpractice is going to pass. When things are done with care and properly, and everything is in the right order, and documented in a way that serves right both the patient and the doctor’s office risks are smaller than there will ever arise a malpractice claim. In the long run, this should be in the focus of the care provider and the patient alike, as both parties are going to have a hard time remembering everything that transpired at the moment when the care was given. Any future issue can be avoided or at least handled when the documentation is formed and stored in the right way.