Healthcare Providers in Documentation

Authenticated, accurate, legible, complete, and timely documentation is paramount to patient safety, quality of care provided to patients, and appropriate reimbursement. Healthcare providers have an obligation to document appropriately, reflecting a true picture of the treatment and services rendered to the patient. Not only does the health record documentation itself need to be of the highest quality, the health record also must be organized and available to the healthcare providers who need it to care for the patient. Physicians, nurses, allied health professionals, and HIM professionals all play vital roles in meeting the documentation standards from a healthcare organization’s policy and procedural perspective and meeting regulatory requirements applicable to health record documentation.