The One Dozen Most Important Things You May Not Have Known, Understood, or Realized About American Medicine
Document, Document, Document! - Overview
The importance of good medical records cannot be overemphasized. Records that are clear, organized, complete, legible, and timely facilitate continuity of care among members of the health care team, minimize the risk of medical errors, offer protection from litigation, support hospital accreditation, and maximize reimbursement. When medical records are handwritten, they must be legible and clear. Only approved abbreviations should be used. Physicians must become adept at using electronic medical record systems appropriately. If something is done but not documented, in many ways it may just as well have never happened. If complications or bad outcomes occur, immediate and thorough documentation decreases the risk of litigation and other adverse consequences. Even mundane details such as recording the date and time of a progress note may prove medicolegally important; therefore, thorough documentation is of great importance.