Documentation is an essential legal requirement in any interaction, and more so in patient management. Failure to document relevant data is a significant breach of deviation from the standard of care. Not only does the patient’s record provide enduring version of the care as it evolves over time and a reference work of value in emergency care, research, and quality assurance – it extends the risk management dimension and liability prevention, by providing protection from legal jeopardy.
The purpose of complete and accurate patient record documentation is to foster quality and continuity of care. It creates a means of communication between providers and between providers and members about health status, preventive health services, treatment, planning and delivery of care.
Our medical record standards should reflect confidentiality and accessibility to authorized users only. Key features:
• A unique, individual record for each patient by Registration.
• An organized record-keeping system to ensure easy retrievability for review and use when needed, and at each patient visit
• Centralized storage in secured location with accessibility to only authorized personnel and electronically secure
• Ensure documents are fastened securely within folder
• Periodic training in confidentiality and security for information handlers