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he medical record is the wellspring of data for
countless decisions regarding patient care from
doctors, paramedical and administrative staff. Even
though, during recent years the ancillary activities
like audit, research, legal etc which depend on the
medical record have received most of the attention.
The most frequent problem encountered by
administrative and medical authorities is probably as
old as the concept of the medical records itself i.e. its
completion in time and in accurate manner. An
inaccurate or incomplete medical record reflects that
the patient care was incomplete. Medical record
which contains gaps depicts poor clinical care,
demonstrate non-compliance with institutional
policies and can be used to support allegations of
negligence or fraud. Moreover, an incomplete
patients clinical documentation can leads to legal
actions, can results in loosing job, contribute to
imprecise quality and care information, leading to
lost revenue/reimbursement to institution or
physician, inappropriate billing and leading to
charges of fraud. In addition, incomplete or improper
documentation interfere with research, data analysis,
patient-related studies and most likely compromises
1,2 safe patient care. That's why every health care
provider institution should ensure timely, precise and
complete clinical documentation of all patients at any
cost.
Ishtiaq Ahmed. (2018) Medical Documentation- An Ignored Aspect in Patient Care, Journal of Islamic International Medical College, Volume-13, Issue-1.
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