logo
logo
Sign in

Know Why Medical Documentation Is the Need of the Hour

avatar
Lezdotechmed
Know Why Medical Documentation Is the Need of the Hour

Do you understand the significance of medical documentation in your life? It is all-inclusive medical data from your childhood to the end of your life. Because medical documentation is used to share health information, health care professionals use it to track an individual's health status. This will assist them in providing proper treatment without error.

An individual's medical documentation includes their medical history, previous diagnoses, medications, surgeries, imaging studies, and reports of X-rays, CT scans, MRIs, ECG reports, lab results, and allergies. A proper medical document will keep track of all vaccination details, including dates. It aids in the planning of future treatment without any uncertainty.

Role of medical documentation in the legal process

Proper documentation of medical data will protect health care professionals from the majority of medical malpractice cases. Because it is all-inclusive data, it reduces the possibility of a medical error. A well-documented medical record aids in identifying gaps in treatment or treatment cancellation or discontinuation. If a patient develops a health problem as a result of his refusal to cooperate, the medical document can protect the physician from a medical malpractice lawsuit. Even if the patient's deteriorating health is the result of a careless healthcare professional, the medical records serve as proof.

Management of medical records

Individuals' sensitive personal information may be contained in medical records. As a result, data privacy gains importance. People who handle medical data should be properly trained in order to maintain data security. Personnel should understand the importance of keeping a medical record and the risks involved in mishandling one. Employee's carelessness is responsible for more than half of all security issues. Keeping medical records on paper is a difficult task. They must be maintained with utmost care.

The majority of hospitals have switched to electronic medical records (EMR). EHRs (electronic health records) can be easily maintained. Medical records, on the other hand, should only be kept for a limited time. The paper records will be shredded after the recommended period, and the EHR will be overwritten with the new records.

Medical record retention period

The federal government insists that an individual's medical data be kept for 5 to 10 years after the patient's last visit. The data will be destroyed at the end of the period. In Columbia, however, physicians must keep medical records for three years after the last visit, and hospitals must keep data for ten years after discharge.

Patients have the right to request medical records under the Health Insurance Portability and Accountability Act (HIPAA). The guardian, parent, caregiver, advocates, or third party can access the patient's medical data with the patient's written consent. The medical record release forms will include information such as the patient's name, date of services, hospital or physician information, information requested, and the reason for the request. The providers must respond within 30 days of receiving the request. You must pay a reasonable fee to obtain a copy of your medical records. If any errors are discovered, you can request that they be corrected.

Conclusion

Physicians and other healthcare professionals must exercise caution when creating an error-free medical record. Avoiding shorthand and abbreviations, unnecessary comments, and adding the date and signing after completing the records will ensure that the medical records are flawless. In any lawsuit, medical records are critical in proving the individual's injury and treatment. Any mistake in the medical records can alter the outcome of the litigations. As a result, make the media records flawless.

To know more visit: Medlegal360

Medicaldocumentation medicalrecordreview

collect
0
avatar
Lezdotechmed
guide
Zupyak is the world’s largest content marketing community, with over 400 000 members and 3 million articles. Explore and get your content discovered.
Read more