Cont… 2.Communication: members of the health care team generally interact with patients at different times during the day, week, or even month

Cont…

2.Communication: members of the health care team generally interact with patients at different times during the day, week, or even month

The patient record may be the only means of communication between various providers

3. Legal documentation: In the event of a lawsuit or other legal action involving patient care, the record becomes the primary evidence for what actually took place during the episode of care

Old but gold, “If it was not documented, it was not done.”

Cont…

• 4. Billing and reimbursement: Insurance companies and other third-party payers insist on clear documentation to support any claims submitted
• Filing a claim for a service that is not clearly documented in the patient record could be construed as fraud
• 5. Research and quality management: used for research purposes and for monitoring the quality of care provided, eg. secondary data analysis