Get Incomplete Medical Records

For a coder, "poor documentation would be defined as documentation that lacks the sufficient specificity to assign accurate diagnosis and procedure codes," Siegel says. In general, Stewart says poor documentation is defined as that which is lacking clarity, specificity, or completeness, and is of overall poor quality.

An accurate written record detailing all aspects of patient monitoring is important, not only because it forms an integral part of the of the provision of care or nursing management of the patient, but because it also contributes to the circulation of information amongst the different teams involved in the patient's ...

A good medical record serves the interest of the medical practitioner as well as his patients. It is very important for the treating doctor to properly document the management of the patient under his care. Medical record keeping has evolved into a science.

Don't obliterate the mistaken entry. ... Make the correction in a way that preserves the original entry. ... Identify the reason for the correction. ... Follow facility policy when adding late information. ... Never alter words or numbers after you've written them. ... Correct mistakes promptly.

Clear and concise medical record documentation is critical to providing patients with quality care, ensuring accurate and timely payment for the services furnished, mitigating malpractice risks, and helping healthcare providers evaluate and plan the patient's treatment and maintain the continuum of care.

Good recordkeeping can help you to find the information you need. It promotes the creation of full and accurate records in the first place. It also involves storing and managing records appropriately so that the information will be available to you when you need it.

Documentation is any communicable material that is used to describe, explain or instruct regarding some attributes of an object, system or procedure, such as its parts, assembly, installation, maintenance and use. ... Documentation is often distributed via websites, software products, and other online applications.

The refer- ence to "incomplete medical records" commonly includes records for services by a physician or other provider that have not been completed by that physician, or records that are insufficient to support the services billed to a third-party payer. ... with a physician or a practice.