Angelo, T. & AWAC Services Company. (2025).
American Professional Agency.
Documentation is the backbone of effective, ethical and legally sound care in any healthcare setting. The medical record/documentation functions as the legal document that supports the care and treatment provided, demonstrates compliance with both state and federal laws, and validates the professional services rendered for reimbursement. This concept is familiar to any provider, and it is recognized that many healthcare providers view documentation as something that is dreaded. The main obstacle may stem from limited time to provide care and complete thorough documentation, the burdensome clicks and rigid fields of the electronic medical record, or the repeated demands from insurance providers for detailed information to meet reimbursement requirements and prove medical necessity for coverage.
Staying vigilant is necessary along with thinking beyond documentation being an expected task but as a critical safety measure. Thorough documentation protects both parties involved in the patient-provider relationship. Documentation ensures the continuity of care and upholds ethical standards of professional integrity and accountability. The age old adage “if it’s not documented, it’s not done” serves as a stark reminder of the potential consequences of inadequate documentation which can result in fines, penalties and malpractice liability. Documentation failures, particularly omissions, have been known to complicate the defense of any legal matter and can favor a plaintiff or disgruntled patient regardless of whether good care was provided. The following scenarios illustrate the significance of documentation and outline best practices to follow.
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Nice quick review about documentation requirements. Refreshers are typically helpful!
