Question

With regards to standards for health records. What are documentation standards and why are they important in healthcare?

Answer 1

ANSWER

Documentation standards

       * A set of rules followed during documentation of a particular data or

         information is known as documentation standards.

* In the case of health records documentation standards includes,

                   * Complete documentation when recording a patient information.

                   * Information recorded about the patient should be accurate.

                   * Patient care documentation should be concise.

                   * Always document factual informations about the patient care.

                   * Document in an organized mannor.

                   * Timely documentation of patient care after it was done.

                   * Documentation should be confidential to maintain code of ethics.

* Importance of documentation standards.

                  * Following documentation standards avoid documentation errors during patient care.

                  * Patients records are used as a legal document so documentation standards needed

                     for accurate recording of patient information.

                  * Documentation standards necessary to respect the privacy of an individual.

                  * Documentation standards enhance professionalism in nursing.

                  * Standard documents can use for research and educational purposes in future.

                  * Documentation standards used to assess the perfomance level of health care

                    providers.

                * Standard documentation help to avoid reimbursement problems at the time of

                     discharge.