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The facts our ne ecific little Page 2 Good record keeping is a vital part
of effective communication in nursing and integral to promoting safety and continuity of care
for patients and clients. Nursing staff need to be clear about their responsibilities for record
keeping in whatever format records are kept.
Records are tools of communication between health workers, the family, and other
development personnel. Effective health records shows the health problem in the family and
other factors that affect health. Thus, it is more than a standardized sheet or a form.
A record indicates plans for future.
It tells the patient's "story": the presenting problem and the treatment received; Helps to plan
and evaluate a patient's treatment; Creates a permanent record for the patient's future care;
Builds a database to evaluate the effectiveness of treatment that may be useful for research and
education
They provide documentation of a patient's continuing health care from birth to death. They
provide a foundation for managing a patient's health care. They serve as legal documentation
in lawsuits. They provide clinical data for education, research, statistical tracking, and assessing
the quality of health care.
Medical records provide documentary evidence of a patient's healthcare information. Though

there is universal acceptance of the importance of medical records, there is disparity in
its application among various nations and systems primarily owing to the differences in cultural
and legal frameworks.
Four Reasons to Document Medical Records Properly

Dr. Thompson cites four reasons why it’s vital to properly document patients’ medical
records.
1. Communicates with other health care personnel
Documentation communicates the quality of clinical care that providers are delivering to
patients and serves as a means to facilitate the patient navigation continuum of care,
from EM to HM and beyond.
2. Reduces risk management exposure
Documentation mitigates risks and reduces the chance of malpractice. A well-
documented record can help alleviate liability concerns in the event of a claim.
3. Records CMS Hospital Quality Indicators and PQRS Measures
Documentation captures value-based purchasing metrics that, increasingly, the
government is asking hospitals to provide. These include Hospital Quality Indicators and
PQRS measures.
4. 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.
"Ninety-five percent of ensuring appropriate reimbursement is just good documentation
practices that every one of our doctors knows," Dr. Thompson says. "The other five
percent consists of learning the rules provided by the federal government and other
organizations that we need to know from a documentation compliance standpoint so
that we are reimbursed correctly."
In addition to these four, other reasons why proper medical record documentation is
important include:
 It tells the patient's "story": the presenting problem and the treatment received;
 Helps to plan and evaluate a patient’s treatment;
 Creates a permanent record for the patient’s future care;
 Builds a database to evaluate the effectiveness of treatment that may be useful
for research and education.
 Documentation is a requirement in just about every job, however, in healthcare, it
has become a vital part of each staff member’s role. From noting what time
medications are given by a nurse, to recording the refrigerator temperature by
the head cook, documentation helps to establish stable routines and fosters
regular communication among staff in the same and different disciplines.
Specifically in nursing, documentation helps to establish continuity of a patient’s
care, justify clinical reimbursement, safeguard providers from malpractice, and
foster communication amongst rotating providers.
 One of the first and most important principles taught in Nursing School is this: “If
you didn’t document it, you didn’t do it.” This rule is meant to protect both patients
and providers, but in very different ways.
 For providers, patient records play an important role in the facility’s ability to
qualify for financial reimbursement from Medicare, Medicaid and other third-party
payers. Additionally, in order to uphold JCAHO accreditation, healthcare facilities
must meet stringent documentation standards. Meeting and exceeding charting
standards also protects nurses providing care from possible ties to negligence or
malpractice.
 For patients, documentation ensures the delivery of safe, consistent, quality
healthcare. Documentation is often the sole point of communication between
nurses of changing shifts. This means that if no verbal conversation has taken
place, the documented notes must be read by the incoming nurse in order to
understand where in the care cycle the patient stands. In the case that a
documentation error, or lack of documentation altogether, leads to a medical
error that threatens a patient’s life, the charting (or lack thereof) protects the
patient in a court of law
Good healthcare providers should strive to improve their charting skills through ongoing
continuing education opportunities. The healthcare arena is an ever-changing industry with
many laws and regulations that have an impact on the documentation process. To learn more
about the Board of Nursing continuing education requirements in Massachusetts, download

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Medical records provide documentary evidence of a patient's healthcare information. Though

Four Reasons to Document Medical Records Properly

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