Healthcare documentation refers to the systematic recording of patient information, including medical history, treatment plans, and progress notes. This documentation is essential for ensuring continuity of care, facilitating communication among healthcare providers, and maintaining accurate patient records. It often includes details about diagnoses, medications, and any procedures performed.
Proper healthcare documentation is crucial for legal and regulatory compliance. It serves as a legal record of the care provided and can be used in case of disputes or audits. Additionally, it supports research and quality improvement initiatives within healthcare organizations, ultimately enhancing patient safety and outcomes.