The more clear you can make your entries in the medical record, the greater impact it will have on how your care is perceived to be rendered.

For example:

  • The medical record is the only written source that displays the events of patient care in chronological order from admission through discharge or death.
  • The medical record is the communication tool used by all members of the healthcare team.
  • The medical record holds the documents that support insurance coverage (payment) or denial.
  • The medical record is the only evidence that represents why patient care decisions were made and on what basis.
  • The medical record is the only legal record.
  • The medical record is the foundation to evaluate patient outcomes.
  • The medical record is the basis for research and education.
  • The medical record serves as the objective source for regulatory compliance agencies review for licensing and accreditation.

The medical record is the only written account of the patient’s stay.

Make every word count!

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