Surgical Procedure Documentation in a patient’s hospital record includes any and all information that relates to the care of the patient throughout their stay or hospital encounter. It is intended to evaluate the current condition of the patient, assist in developing a plan of care, evaluate the care given, and provide for continuity of care.
Good and complete documentation in a patient’s health record has been linked to both qualities of care and health care costs. Detailed and accurate chart documentation facilitates appropriate medical care, helps reduce medical errors and supports the continuity of care. It is critical that it be accurate and complete. Complete and accurate health records also ensure that all clinical staff caring for patients in present and future encounters of hospitalization has access to the information they need to deliver optimum care. This section will examine the patient record’s effect on:
- Patient care and clinical outcomes
- Physician-to-physician communication
- The health care system