The importance of documentation in Health and Social Care

Proper documentation has always been important for jobs with Health and Social Care – specifically in nursing & nurses need to dedicate their time to it. Let’s take a look at few reasons for proper documentation in healthcare.

Reasons for proper documentation

Continuity of a patient’s care

Documentation is the channel of communication between nurses of changing shifts. In case verbal communication hasn’t happened between them, a well-documented record can help the nurse to understand where in the care cycle the patient stands. Lack of documentation can prompts a clinical error that might be life-threatening for a patient.

To justify clinical reimbursement

A well-documented medical record plays an important role to ensure appropriate financial reimbursement from Medicare/Medicaid or other third-party payers.

To safeguard providers from malpractice

Proper documentation helps to reduce the chance of malpractice.

To establish stable routines

It could be difficult for nurses to remember the details about the care provided to a particular patient since they are providing care to hundreds of patients. In this case, a well-documented record provides the evidence to the nurse to relate as precisely as possible what happened. Starting from noting down the time of medications given by a nurse, to recording the refrigerator temperature, proper documentation has always been helpful to establish stable routines.

Other reasons

In addition to the above reasons, other reasons for proper documentation includes,

• It protects you & your colleagues! When the hospital staff does everything right, sometimes the patients may not always respond to the given care. If things ever go wrong, the patient’s medical record might help you to defend yourself/your colleagues/your hospital against a lawsuit.
• It helps in building a database to evaluate the effectiveness of treatment which may be useful for research/education.
• It also ensures timely payment
• It helps to plan & evaluate a patient’s treatment
• It helps in keeping a permanent record for the patient’s care in future