Accurate and complete medical record documentation is essential in any healthcare setting. In addition to communicating vital patient care information, the medical record provides documentation of appropriate evaluation, treatment, and services. It also is used to evaluate practitioner performance, to monitor resource use, and to determine reimbursement. In this article, Carol Ann Martin describes the efforts of one hospital to revise and upgrade its medical record documentation by means of continuous quality improvement strategies.
AbstractAccurate and complete medical record documentation is essential in any healthcare setting. In addition to communicating vital patient care information, the medical record provides documentation of appropriate evaluation, treatment, and services. It also is used to evaluate practitioner performance, to monitor resource use, and to determine reimbursement. In this article, Carol Ann Martin describes the efforts of one hospital to revise and upgrade its medical record documentation by means of continuous quality improvement strategies.