04.12.2020 in Nursing
Health Records

Comprehensive H&P Case Study

Medical records are crucial in documenting the condition and care history of patients, which is an important requirement in continuous care. Essentially, medical records constitute part of a providers statutory and ethical duty to offer high quality patient care. Accurate documentation of care activities promotes the best interests of providers and patients albeit for different reasons. The accurate documentation of all pertinent information regarding patient care plays a crucial role in helping providers to monitor patients and lessens the risk of medical errors during treatment. Medical records are used for documenting observations, findings, and relevant facts regarding the health history of a patient as well as the present and past illnesses, tests, examinations, and outcomes. Medical records are organized chronologically for documenting the care that a patient receives, and is a crucial prerequisite for providing high quality care. This paper discusses the importance of accurate medical record documentation.

Basic Medical Records Documentation

Good documentation of medical records captures the fundamental aspects related to patient care, which includes what was done to the patients, who did it, and the outcomes of that particular action. Having pertinent medical documentation in a single place plays a crucial role in supplementing the memory of a healthcare practitioner regarding critical events that occur during treatment. In addition, accurate documentation of the symptoms and complaints raised by the patient can help the healthcare practitioner in the identification of trends and act as a guide during the development of a treatment plan. Also, through accurate documentation of medical records, physicians and other practitioners can assess and plan treatment for the patient and monitor the care outcomes over time.

Improvements in Care Outcomes

Improved care outcomes is one of the important reasons for ensuring proper documentation of medical records. Keeping accurate medical records of patients has been associated with improvements in the clinical outcomes of patients. As Jensen et al. reported, approximately 20% of patients undergo adverse events following discharge such as procedural complications, infections, and drug reactions among others. The bulk of these problems are attributable to incomplete or delayed information provided to the subsequent providers of care. In addition, Jensen et al. reported that patients having considerable gaps in their health records spend longer in emergency rooms, approximately 1.2 hours more. Improved care outcomes from accurate documentation of health records stems from the fact that it is essential in facilitating communication as well as continuity of care among practitioners involved in the provision of care to the care of the patient. Fundamentally, ensuring the patient is provided with the best available healthcare poses the need for effective sharing of information between an interdisciplinary team. Evidence also suggests that incorrect information found in health records can cause death or serious injury to patients.

The 1997 Guidelines of Documentation for Evaluation and Management states that emphasis should be placed on five factors accuracy, timeliness, confidentiality, completeness, and relevance – to ensure quality care as well as the useful of the information documented. Particular emphasis is placed on accuracy wherein each individual health record should be correct. This is because, throughout the lifetime of a patient, his/her medical record will form the basis of treatment. Additionally, inaccuracies result in the provision of improper health advice leading to adverse patient outcomes. Overall, accurate health records documentation is needed to improve patient outcomes.

Defense against Medical Malpractice

Documentation of medical records is one of the few topic in medical law that has generated considerable discussion. Third-party payers, defense attorneys, and liability insurers often emphasize the importance of physicians and healthcare practitioners taking steps to ensure the safety of patients. The consequence of litigation and the timeliness of payment reimbursement depends significantly on the accuracy, timeliness, completeness, legibility, and adequacy of the health records. In most medical malpractice claims, the plaintiff often wins due to poor health records, even in situations involving the provision of appropriate health care. As a result, it is imperative for providers to ensure that they keep complete and well-organized health records. Providers who fail to maintain adequate health records spend significant time in deposition and worrying about the impact of the case in their practice reputation. The time it takes to prepare for litigation is far more than the time required for maintaining accurate heath records.

Accurate health records documentation has been described as the best defense that providers can use against claims of malpractice. From the perspective of juries and judges, a procedure that is not indicated in a chart simply means that it has not been done. Thus, providers must make sure that all procedures not only done, but they should also follow up with the patient, which helps in minimizing risks associated with missed diagnoses. Accurate keeping of medical records is also crucial when handling abusive patients and those who do not adhere to medical advice. In addition, accurate documentation of health records can alleviate the hassles involved in processing claims since it acts as a legal documents that affirms care was provided. Skimpy, inaccurate, and illegible medical records are a sure way of losing medical malpractice claims. Therefore, accurate documentation of health records can help providers avoid the negative legal consequences by providing confirmation that appropriate care was offered to the patient in question. This means that accurate documentation of health records is essential in helping providers to circumvent liability.

Quality Assurance

Accurate documentation of health records contrite to quality assurance. As Lindh et al. explained, noting down initial evaluations and patient progress enhance patient care since it compels providers to think cautiously regarding their actions. With time, the self-reflection capability of healthcare practitioners is developed, which is important in their professional development, maintenance of professional skills, and offering high quality care. Additionally, through accurate documentation of health records, the treatment team can collaborate and share knowledge and coordinate their strategies, which contributes to improvements in the quality of care.

Meeting Payers Demands

Since payers are contractually obligated to their enrollees, they need confirmatory document to indicate that the services provided are congruent with the specific type of insurance coverage. As a result, they might demand information for purposes of validating the site at which the healthcare service was provided; the medical requirement and the suitability of the therapeutic and diagnostic services offered; and whether the healthcare services offered have been documented and reported accurately. To this end, healthcare providers have an obligation to deliver accurate health records accompanied with sufficient back up to prove their payment claims. Therefore, accurate documentation of health records is one of the ways in which providers can meet the demands posed by payers.

Ensuring Patient Safety

Accurate health records documentation has been linked to improvements in patient safety. The complexity associated with the process of delivering healthcare is increasing and the amount of healthcare data is also growing, which underscores the importance of accurate documentation of health records. Since patients are seeing several different specialist and doctors, accurate documentation is a must. Also, providers cannot depend solely on memory; hence, the need for accurate and complete health records. Inaccurate documentation is not just an issue of problem of paperwork; instead, it can endanger the health of a patient. Essentially, health records serve as a clinical decision-making tool; thus, any inaccuracy might result in adverse outcomes for the patient.


Accurate documentation of health records is beneficial for both patients and providers. From the perspective of patients, accurate health records documents ensures that they receive high quality, and safe care, which results to improvements in their clinical outcomes. From the perspective of providers, accurate health records documentation is needed to avoid liability from medical malpractice claims; facilitates communication between providers; contributes to quality assurance; and ensures that meet the requirements of payers. Taken together, accurate documentation of health records fosters continuity as well as the quality of care.

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