A Guide to Medical Record Documentation Do’s and Dont’s That You Should Know

medical record documentation do and don'ts

Medical Record Documentation is essential to providing quality care to your patients, but it also serves another crucial purpose. If a patient decides to take legal action against you or a member of your practice, these records play a vital role in building a defense. This article will cover some medical record do’s and don’ts that can help protect you from liability in the field of health care.


Do: Take Detailed Documentation

When providing patient care, it is essential to document everything you notice closely. While some interactions may seem completely routine and demand less attention, this mindset is dangerous. Even a patient who appears normal during your examination can develop a severe condition quickly, which can lead to the patient pursuing a failure to diagnose claim.

In these cases, the court will scrutinize the quality of the medical documentation noted by the physician to determine whether they should have diagnosed the issue. Therefore, keeping good documentation and ensuring it’s concise but detailed is vital for protecting yourself in your practice. If you’d like to make sure you’re recording things correctly, once you finish this list of medical record do’s and dont’s, visit the PracticeForces website for a guide to medical billing errors and many other helpful articles.


Don’t: Rely Too Heavily on Phone or Video Calls

As technology advances, it becomes a more significant part of nearly every aspect of our lives. 

During the recent pandemic, phone and video appointments became a crucial part of healthcare to minimize face-to-face contact. However, it is important not to over-rely on these tools, as they limit medical providers’ ability to diagnose certain illnesses effectively.


Do: Document Discharge Instructions

Discharge instructions are a vital part of continuing care for your patients, and they also play a role in court proceedings. It’s important to include detailed instructions for how your patients should respond to specific symptoms, particularly if severe complications are a concern. Making sure your patients know when they need to return for additional treatment is essential to keeping them safe and you protected.  


Don’t: Document Negative Comments

While situations may arise where a conflict occurs between people in your practice, it’s crucial to stay professional. Patients can view medical records under specific conditions in many areas, so maintain an objective tone throughout your notes. This practice will also be a significant help during a court case, as a judge may look unfavorably at messages that come off as dismissive or rude.


Do: Work With an Expert Medical Billing Company

Utilizing a medical billing company like PracticeForces can streamline the process of taking and maintaining medical records. At PracticeForces, we understand the importance of managing medical records in your practice, and our team is happy to provide guidance.

If you think you need help with your medical records or want to learn more about telemedicine, PracticeForces is here to help. The knowledgeable staff at PracticeForces has years of experience in the medical field and is available to answer questions on the website or by phone. If you’d like to use the medical record documentation do and don’ts you learned in this article to optimize record keeping in your practice, call PracticeForces today at (727) 499-0351.

Parul Garg, CEO and co-founder of PracticeForces, has significantly contributed to the growth of over 1,000 U.S. medical practices through her expertise in medical billing and coding since the company’s inception in 2003. With a background in Computer Science and an MBA in Human Resources, her leadership and AAPC-certified coding skills have been pivotal in managing the company’s operations effectively.

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