The benefits of quality patient medical record documentation: An investigation of the documentation process for acute hospital record management.

摘要

The purpose of this project was to investigate the complex policies and business practices directed toward establishing quality medical record documentation within the acute health care industry. My research reviewed complex government and private documentation regulations, which challenge hospital administrators, physicians, and managers of health information. This research provided an opportunity to investigate recommendations for the quality documentation processes for the acute care medical record, for use by clinicians, medical record managers and other health care administrators.; In my research, I provide examples of acute care organization where strategic medical record documentation successes have been achieved. Successful documentation plans can eliminate deficient medical record documentation, which hinders patient care, exposes providers to extensive legal and government penalties, and reimbursement inaccuracies.; Based on my investigation, my project concluded with a procedure for improving patient medical record documentation to meet medical record industry requirements.