Medical Documentation
Medical 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, as it allows healthcare providers to track a patient's progress and make informed decisions about their treatment.
Accurate medical records also play a crucial role in legal matters, billing, and research. They help protect both patients and providers by providing a clear account of the care delivered. Proper documentation is vital for maintaining quality standards in healthcare and ensuring compliance with regulations.