MCCG262 Professional Coder Practicum Documentation Presentation (Medical Billing and Coding)

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Professional Coder Practicum Documentation Presentation

In every organization, the letters, invoices or any material document that was used in transactions need to be organized appropriately. The process of classifying and keeping these materials refers to documentation. Therefore, for the proper running of am a medical facility, documentation is vital. Therefore, it is necessary to have appropriate documentation if an organization wants to succeed. To an individual also, the documentation tells more about the person. It is common for organizations that lack proper documentation often ten to fail towards the achievement of its goals. The paper will depict on the reasons as to why documentation is essential and also look at ways of ensuring accurate and complete documentation.

In any medical institution or center, documentation plays an important role. The documents can be about the health of a patient. Proper documentation will enable a nurse or any other medical practitioner to have a historical background of a patient's treatment. The information that the medical practitioner gathers from the documentation of the patient's record is vital in ensuring proper continuity of treatment (Dillon et al. 919). Additionally, adequate documentation allows for the monitoring of the health progress of a patient. All the data that he or she will be gathering will assist in the evaluation of any improper activity concerning the patient’s health, thus making the continuous process of treatment much more manageable.

In the field of medicine, a lot of irregularities may occur, especially when it comes to the treatment of severe ailments. Patients may sue the health center as a result of poor treatment. Therefore, it is necessary for any institution to protect its self from any lawsuit. The best way of avoiding such lawsuits is through proper documentation (Dillon et al. 921). Documentation of how one treated his or her patient, for example how the patient responded to the treatment in various situations, will assist the medical practitioner when it comes to a lawsuit. Additionally, proper documentation to a physician is vital since it shows that one is compliance and also prevents an individual from losing his or her license

Lastly, it is everyone dream of having an improvement in his or her professional. Records of successful treatment of a patient will need documentation for future reference in case such a situation occurs (Dillon et al. 923). Also when dealing with new patients, it will be essential to keep proper documentation, for example, the approach used to tackle the condition. Lastly, it will be necessary to keep a record of the results after the treatment of a patient. Documentation will assist in evaluating whether the approaches used can give a positive outcome.

It will be not wise to have outdated documentation. Proper documentation entails having up to date documents as well as accurate and complete documents. Specific ways should be followed to ensure accurate and complete documentation.one of the most efficient means of providing accurate and complete documentation is a regular checkup of all the processes and assessment of whether all the relevant information have been recorded (Kettenbach, Ginge, and Schlomer 57). It is essential since it identifies any changes that might have occurred. The regular checkup will ensure all that was done since the previous documentation is recorded. Additionally, it will be essential for one to take time in being confident that what he or she has noted down is the exact thing. It is common for medical staff to have a harried and hectic day, thus causing errors during documentation.

In conclusion, it is essential for any organization or an individual to have proper documentation for their safety. Proper documentation saves an individual or organization the risks associated with lawsuits as well as the risk of losing their license. A patient can also have better treatment as a result of proper documentation. For example, the medical practitioner will be able to access previous files of the patient. Lastly, for accurate documentation, it is necessary for a regular checkup to see if there are any changes made. As a medical staff, it is essential to be sure of the records made irrespective of being tired.

Works Cited

Dillon, Ellis, et al. "Provider Perspectives on Advance Care Planning Documentation in the Electronic Health Record: The Experience of Primary Care Providers and Specialists Using Advance Health-Care Directives and Physician Orders for Life-Sustaining Treatment." American Journal of Hospice and Palliative Medicine® 34.10 (2017): 918-924.

Kettenbach, Ginge, and Sarah L. Schlomer. Writing Patient/Client Notes: Ensuring Accuracy in Documentation. Philadelphia, PA: FA Davis Company, 2016.