Good documentation can assist you in avoiding being held liable and staying out of fraud and abuse issues. The value of surgical history to surgeons cannot be overstated. The provider’s history may also indicate some health-related factors that will guide care, such as avoiding potential harm to the patient due to allergies or previous therapies that limit care at the time of contact. Complete and accurate medical recordkeeping can help ensure that your patients receive the proper care at the right time. That’s all that matters. To protect yourself as a provider, you must have the appropriate paperwork.
Discharge Summary
A discharge summary is a handover document that describes why the patient was hospitalized and what occurred to them while in the hospital.
