The nurse should make a copy to scan in the client's medical record.
Why should medical reports be documented properly?
Properly documenting patient’s medical records has always been important, but never more than now, given today’s healthcare landscape where the government ties reimbursement to the quality of the medical record.
The 4 main reasons are:
- Communicates with other health care personnel: Documentation communicates the what, why, and how of clinical care delivered to patients. These records allow other clinicians to understand the patient’s history so they can continue to provide the best possible treatment for each individual.
- Reduces risk management exposure: Thorough and accurate documentation mitigates risks and reduces the chance of a successful malpractice claim. A well-documented record serves as evidence of treatment and care, helping to alleviate liability concerns in the event of a claim.
- Records CMS Hospital Quality Indicators and PQRS Measures: Documentation captures value-based care metrics that, increasingly, the government is asking hospitals to provide. These include Hospital Quality Indicators and MIPS measures.
- Ensures appropriate reimbursement: A well-documented medical record can facilitate effective revenue cycle processes, expedite payment, reduce any “hassles” associated with claims processing, and ensure appropriate reimbursement
To learn more about medical records,
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