A well-written medical record documentation template promotes patients and physicians best interests for different reasons. These documents have been compiled and maintained by the health care providers and usually it is enforced as a licensing or confirmation imperative. A medical record documentation template written by a qualified doctor of health care or physician provides accurate and complete information about the medical history, diagnosis as well as treatment of patient. Normally these documents are the proof and record of the patient’s health and every medical-related incident happened to the patient since birth.
Importance of Medical Record Documentation
It is one of the crucial documents which will ensure the continuity of care for patients. It is vital to take medical record documentation as the further treatment is based on the previous record. These templates could be handwritten or electronic preparing by using software or templates. Health professionals and other physicians require medical records to reconstruct the essential parts of each patient contact, without the need to refer to memory. These are comprehensive and can be put to use at once after downloading.
Details of Medical Record Documentation
It is used for patient to help him/her and includes following information such as patient name, date of inspection, family history, surgical history, social history, habits (smoking, drinking, exercise and diet), vaccinations records, growth charts, medical encounters, history of present illness, progress notes and result of latest tests. The basic purpose of complete and accurate this format of a patient care is to foster quality as well as continuity of care. The document creates a means of communication between providers and members of the health care system. We need to establish an organized recording keeping process to make sure that medical record documentation templates are easily available for review and for use when needed.
