Importance of Documentation

Medical Documentation is very important from a Clinical, Financial and Legal standpoint. 

From a Clinical perspective medical documentation establishes the following,

• the Patient receiving the Service
• the Physician providing the Service
• the Plan of Care provided by the Physician
• the Diagnosis justifying Medical necessity
• the Procedures performed, the Labs ordered
• the Quantity of Service such as consumables
• other details such as Place of service / Date of service e.t.c

From a Financial perspective medical documentation establishes the following,

• proper adjudication of claims
• timely payment of claims

From a Legal perspective medical documentation establishes,

• the justification for the procedures performed
• Legal protection for the Patients and Physicians

The Physician / Provider has to document all the procedures performed and sign the document, procedures that are not documented would be considered as not performed and would not be eligible for payment.