Helping patients maintain their overall well-being is your top priority as a health care provider. To that end, medical documentation is a crucial part of the process. When done properly, it allows for better care and patient safety while mitigating the effects of a malpractice suit should it occur. Here are some guidelines to embrace if you're looking for ways to improve documentation practices. 

Do:

Use specific language.

Creating a detailed list of symptoms will assist with diagnosing a patient, as long as you use the right language to outline their problems. For example, if a patient complains of back pain, ask follow-up questions to determine the location, pain levels, and whether it's sharp, throbbing, or acute. 

Perform your assessments and document the results in as much detail as possible. Should the patient mention other chronic conditions or recent illnesses, include this information in your medical documentation. These measures help avoid vague records that could lead to poor care.

Consider virtual scribes. 

While you meet with a patient, a virtual scribe can listen in on the appointment and take thorough, copious notes. With their help, you can rest easy knowing the entire assessment is added to medical records in a timely and factual manner without any missing details or inaccuracies. As a result, you can focus on listening to your patient's symptoms and finding the proper diagnosis and treatment plan. 

Don't:

Copy old information. 

Patient care documents should be stand-alone entries. During each medical appointment, you'll need to write a report as if it's the first time you've met with the individual. Refrain from adding commentary from previous patients or copying other records. The documentation must corroborate the services rendered and deem them medically necessary.

Delay your entries.

Medical documentation must be generated during the appointment or shortly after that. Sometimes records get delayed to add in details or correct errors, but they should still be completed within 24-48 hours. Promptly completing the entries ensures accuracy and that your practice's billing department can liaise with insurance companies on time.

If you need assistance with medical documentation, My Virtual Scribe in Camarillo, CA, can help. They ensure medical professionals across the United States and Canada can focus on providing top-notch health care services by offering them HIPPA-certified virtual scribes who use safe, high-tech practices. Visit the website to register for a scribe, or call (310) 919-4278 for a consultation.