Patient Documentation
Patient Documentation refers to the systematic recording of a patient's medical history, treatment plans, and progress notes. This documentation is essential for ensuring continuity of care, as it provides healthcare professionals with vital information about a patient's condition and treatment history.
Accurate Patient Documentation helps in legal protection, billing, and quality assurance. It includes various forms such as medical records, progress notes, and discharge summaries, which are crucial for effective communication among healthcare providers and for making informed decisions regarding patient care.