Introduction to Documentation Concepts
Documentation is the universal language of the health care record. Basically, if the treatment is not documented, it never happened.
In this program, we begin right away with introducing the role of documentation. Keep in mind that we will be working throughout the year on the key concepts and essential components of clinical documentation. Initially, you may find the information challenging. Be assured that as we integrate clinical examples in lecture and laboratory practice, you will become more comfortable with applying documentation skills.
Failure to document accurately and thoroughly, using neutral language which is clinically relevant to the case compromised patient safety, outcome measures and the continuum of care. Additionally, inaccurate, inappropriate, or incomplete documentation violates federal law, state practice acts, Medicare guidelines, and Standards for Ethical Conduct.
Be sure to check your study guide for some common abbreviations. We will start using some of these abbreviations in lab and lecture activities, so it will be helpful to keep your own copy for quick and easy reference.
