Maintaining Accuracy and Compliance in the Medical Record

Why is accuracy and compliance to accepted standards of documentation in the medical record important? The first and most important reason is to provide patients with appropriate care based on details provided in their medical record. This ensures optimal patient care and allows for excellent patient satisfaction. Another reason for ensuring accuracy and compliance in the medical record is to provide governmental agencies, and any other entity accessing the patient’s medical record accurate and complete information. With improved documentation, collections improve, the risk for unfavorable audit results decreases, and efficiencies are increased in the office with both staff and physician co-workers.