Quick Answer: What Are Five Characteristics Of Good Medical Documentation?

What is patient documentation?

Proper documentation, both in patients’ medical records and in claims, is important for three main reasons: to protect the programs, to protect your patients, and to protect you the provider.

Good documentation is important to protect your patients.

Good documentation promotes patient safety and quality of care..

What are the characteristics of good medical records?

6 Key Attributes of a Medical RecordAccuracy of the medical record. The accuracy of the data refers to the correctness of the data collected. … Accessibility of the medical record. … Comprehensiveness of data. … Consistency of information in the medical record. … Timeliness of information. … Relevancy of the medical records.

What records should be kept?

When to Keep and When to Throw Away Financial DocumentsReceipts. Receipts for anything you might itemize on your tax return should be kept for three years with your tax records.Home Improvement Records. … Medical Bills. … Paycheck Stubs. … Utility Bills. … Credit Card Statements. … Investment and Real Estate Records. … Bank Statements.More items…•

What are types of medical records?

There are two different documentation formats that are used for medical records, the source-oriented medical record and the problem-oriented medical record. The more traditional format used for recording data in the medical record is the source-oriented medical record (SOMR).

What is proper documentation?

Proper documentation provides evidence of what has transpired as well as provides information for researching discrepancies. Supporting documentation may come in paper or electronic form. In recent years, more often, official supporting documentation has moved from paper based to electronic forms.

What does documentation mean?

Documentation is a set of documents provided on paper, or online, or on digital or analog media, such as audio tape or CDs. … Paper or hard-copy documentation has become less common. Documentation is often distributed via websites, software products, and other on-line applications.

What are characteristics of records?

Four essential characteristics: – Authenticity-A record must be what it purports to be. – Reliability-A record must be a full and accurate representation of the transactions, activities, or facts to which it attests. – Integrity-A record must be complete and unaltered.

What are the characteristics of a hospital?

Becoming Great: 5 Common Characteristics of the Best HospitalsPut Patients First. It’s one thing to say you put patients first. … Deliver Compassionate Care. Patients enter through hospital doors at the most vulnerable time in their lives. … Commit to Excellence. … Foster a Culture of Innovation. … Trust Spok for Communication.

What are the types of records?

Some of the most significant record types are:Property records – title deeds and settlements.Accounting papers – including rentals, vouchers, surveys and valuations.Legal papers.Inventories.Correspondence.Enclosure papers.Manorial papers – court rolls, custumals, terriers, surveys etc.Personal and political papers.More items…

What are the four purposes of medical records?

It tells the patient’s “story”: the presenting problem and the treatment received; Helps to plan and evaluate a patient’s treatment; Creates a permanent record for the patient’s future care; Builds a database to evaluate the effectiveness of treatment that may be useful for research and education.

Why is it important to keep medical records?

The most important reason for keeping a medical record is to provide information on a patient’s care to other healthcare professionals. … Another major rationale is that a well-documented medical record provides support for the physician’s defense in the event of a medical malpractice action.

What is the purpose of documentation?

The purpose of documentation. … The purpose of documentation is to: Describe the use, operation, maintenance, or design of software or hardware through the use of manuals, listings, diagrams, and other hard- or soft-copy written and graphic materials.

What is the importance of accurate documentation?

An accurate written record detailing all aspects of patient monitoring is important, not only because it forms an integral part of the of the provision of care or nursing management of the patient, but because it also contributes to the circulation of information amongst the different teams involved in the patient’s …

What are the 3 main types of records?

Some of the most significant record types are:Property records – title deeds and settlements.Accounting papers – including rentals, vouchers, surveys and valuations.Legal papers.Inventories.Correspondence.Enclosure papers.Manorial papers – court rolls, custumals, terriers, surveys etc.Personal and political papers.More items…

What records need to be kept?

To be on the safe side, McBride says to keep all tax records for at least seven years. Keep forever. Records such as birth and death certificates, marriage licenses, divorce decrees, Social Security cards, and military discharge papers should be kept indefinitely.