Health Documentation
Health documentation refers to the systematic recording of patient information, including medical history, diagnoses, treatments, and outcomes. This documentation is essential for ensuring continuity of care, allowing healthcare providers to make informed decisions based on a patient's past and current health status. It typically includes various forms such as medical records, progress notes, and treatment plans.
Accurate health documentation is crucial for legal and regulatory compliance, as it serves as a legal record of the care provided. It also facilitates communication among healthcare professionals, ensuring that everyone involved in a patient's care is aware of their health needs and treatment plans.