Importance of Keeping Medical Records
Most healthcare organizations follow the maxim "If it was not documented, it was not done," which emphasizes the significance of keeping medical records. It emphasizes the medical procedure that adopts thorough and regular documenting of every patient's medical file necessary for efficient and high-quality care. This method of documentation is required to document crucial patient discoveries, facts, and observations that must meet certain compliance standards (Groth, 2015). It acts as a crucial conduit for helping medical professionals create a patient's treatment plan over a predetermined time frame. Maintaining medical records enables healthcare institutions to track statistics on healthcare. Besides, the documentation process act as prove for Medicare and Medicaid insurance providers that the services recorded are consistent with the medical services provided in the coverage (Meisel, 2015). Therefore, by keeping organized medical records, health care organizations allow the physicians, insurance payers, staff, auditors and physicians to acquire comprehensive information about the patients.
Impact of Inaccurate Documentation on Billing
As indicated in this rule, the practice of maintaining accurate and complete medical records facilitates the billing process from third party payers. For example, my brother once failed to receive prompt payment from Medicaid for treatment services offered to him in a health care facility due to poor documentation. The health care practitioner who offered treatment documented his medical records inappropriately. As a result, Medicaid ordered the facility to carry out an accurate and complete documentation as well as a consistent coding and billing process that adheres to the standard practice. In the process, his medical cover was delayed.
References
Groth, J. L. (2015). Patient records and clinical overview: The creation of clinical overview
among physicians in daily clinical practice: PhD dissertation. Aarhus: Arts, Aarhus University.
Meisel, A. (2015). Patient Records. Journal of the New Jersey Dental Association, 86, 3.
