Role of Health records Documentation

Role of Health records Documentation

Health record documentation plays a variety of roles within the clinical healthcare setting. Documentation is a communication tool between and among healthcare providers. It allows for continuity in the care and treatment of the patient from one healthcare provider to the next and creates a permanent health record for all future care of the patient. The documentation that is generated during the care and treatment of the patient is the starting point for the revenue cycle, which facilitates the coding and billing of the care and treatment. When the documentation is of the appropriate quality, it serves as proof of care and services and demonstrates that documentation standards are met (or not met). The next section will discuss the principles, codes and beliefs, and guidelines related to documentation standards.