Inadequate Documentation Can Be Extremely Costly

McMurtrie, Daniel G.
December 2003
Click (1532-0391);Dec2003, p8
The article focuses on the need of maintaining proper documentation in medical practice. Health care spending in the U.S. in the year 2000 exceeded 13.2 percent of gross domestic product, and is expected to rise to $3.1 trillion over the next 10 years. One major area that needs constant management is the documentation in medical records. Without continuous vigilance, the result is inadequate and poor documentation that can burden a system into obscurity. Clear and accurate documentation of the care given to patients is the professional responsibility of physicians and other health care providers. Regardless of where the patient receives care, the medical decision making resulting from a patient encounter begins a process.


Related Articles

  • The Long and Short of EHR Documentation. KNUDSON, JULIE // For the Record (Great Valley Publishing Company, Inc.);Jan2016, Vol. 28 Issue 1, p18 

    The article offers information on several developments related to the documentation of electronic health record (EHR). Topics discussed include too much information coming at dense forms, and conduction of a study named Physician Information Needs and Electronic Health Records (EHRs): Time to...

  • Record Limbo: HYBRID SYSTEMS ADD BURDEN AND RISK TO DATA REPORTING. Dimick, Chris // Journal of AHIMA;2008, Vol. 79 Issue 11/12, p28 

    The article reports that the Health Information Management (HIM) departments in the U.S. have to adopt the record limbo, switching between electronic systems and old paper documents. It explains that HIM professionals working with a hybrid medical records have faced many challenges that affect...

  • A Paper Trail to Better Health Care. Russell, Donna // Louisville Magazine;May2005 Supplement, Vol. 56, p22 

    The article informs that keeping a track of the family's medical history and records can ease the stress of doctor's visits and save one's time and money. Organizations such as the American Health Information Management Association, advocate keeping personal health records, a streamlined medical...

  • CPOE Systems Roll out Slowly.  // Journal of AHIMA;2009, Vol. 80 Issue 8, p14 

    The article reports that only 6 out of 10 CIO members of the College of Healthcare Information Management Executives report that their organizations presently have computerized provider order entry (CPOE) systems. It is stated that the current use of CPOE systems is relatively low, even for...

  • Why clinical information standards matter. Gardner, Martin // BMJ: British Medical Journal (International Edition);5/24/2003, Vol. 326 Issue 7399, p1101 

    Editorial. Discusses an article in this issue by Brown et al, which describes a crossover trial comparing the accuracy and usability of two clinical terminology standards in a setting designed to reflect tasks and circumstances commonly encountered in British general practice. View that...

  • Strengthening primary care with better transfer of information. Reid, Robert J.; Wagner, Edward H. // CMAJ: Canadian Medical Association Journal;11/4/2008, Vol. 179 Issue 10, p987 

    The article comments on the article that uncover an unpleasant truth about the degree of clinical information that is transferred between community physicians in a large Canadian province. It cites that the traditional ways of transferring health care information among professionals are...

  • Use of Electronic Medical Records in Oman and Physician Satisfaction. Farsi, Mohammed Al; West Jr., Daniel J. // Journal of Medical Systems;Feb2006, Vol. 30 Issue 1, p17 

    The Electronic Medical Record (EMR) is a computerized record of clinical, demographic and management information. EMR is an enabling technology that allows physicians to utilize quality improvement processes in the practice of medicine. Oman is one of the Middle Eastern Countries that has...

  • in brief.  // Journal of AHIMA;2009, Vol. 80 Issue 2, p10 

    The article offers news briefs related to healthcare industry in the U.S. California-based St. Joseph Health System will carry out Allscripts-Misys Healthcare Solutions' Enterprise Electronic Health Record and practice management software. Medfusion will enforce Web site development and...

  • Physicians and information systems. Kilbridge, Peter M. // Healthcare Executive;May/Jun1998, Vol. 13 Issue 3, p60 

    Focuses on the importance of physicians' use of advanced clinical information systems within the healthcare management. Factors contributing to importance of physicians use of information systems; Effect of physicians' use of information systems on leading healthcare organizations.


Read the Article


Sorry, but this item is not currently available from your library.

Try another library?
Sign out of this library

Other Topics