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 documentation also plays a crucial role in legal and billing processes. It serves as a record that can be referenced in case of disputes or audits, ensuring that healthcare providers are reimbursed for their services and that patients receive appropriate care based on their documented needs.