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The importance of documentation for health care professionals

Working in the healthcare industry is an immense responsibility. Patients trust their doctors, nurses and other types of care providers to provide them with quality care and support. Unfortunately, treatment efforts do not always go as planned, and Texas patients may believe that their provider is responsible for a failed treatment plan or unexpected side effects. Doctors could face accusations of improper care, negligence and other negative things that could impact their reputations and careers.  

This is one of the many reasons why it is important for doctors to be diligent about keeping proper documentation. Keeping up with paperwork and carefully documenting care plans and other details about patient care can prevent many problems in the future. Documentation offers protection against accusations of any type of medical malpractice, providing a way to defend against claims and prevent damage to one’s career in the medical field.  

Your documentation methods matter 

Charting typically includes documenting problems, current health status, possible diagnosis and more. However, it may be beneficial to include more than just the bare minimum of information. This reduces errors, allowing a doctor to track progress in a specific case and provide the information necessary to properly bill for the service provided. Documentation protects both you and the patient, ensuring quality care that is necessary for the specific issue and ensuring that you have the information necessary to make the best possible decisions on behalf of the patient. 

In a patient’s file, you should be able to find all pertinent information regarding health history, past visits, treatment plans, current goals, prognosis and other details that are important. Not only will this help you remember how to proceed with a specific patient, but it also lays the groundwork for continuity of care in case the patient sees a different provider. It also allows you to provide the appropriate follow-up care as needed. 

Your legal and financial interests 

Documentation is critical in the event that you face accusations of improper patient care of any kind. However, it can also allow you to ensure that you receive proper pay through correct billing. Taking the time to carefully document is good for your legal interests, improves the quality of care you provide to your patients and ensures that you have what you need to defend yourself in case of a claim or accusations from a patient.