The Importance of Accurate Medical Documentation
Do you ever get tired of filling out paperwork at the doctor’s office? It’s a necessary inconvenience. Medical documentation serves more purposes than most people initially realize, from preventing deadly diseases to providing evidence in criminal cases. When medical documentation isn’t accurate or unavailable, it can have a severe impact on your life and the lives of others.
Safer Medical Treatment
Thorough and accurate documentation provides medical teams with a complete patient history. It alerts doctors to any health conditions they should be aware of before administering treatments. Medical histories include details about allergies, immunity, and potential contagious diseases a patient might have. If medical documentation isn’t accurate, they might administer medications that a patient is fatally allergic to or that could lead to serious complications. If a patient has a serious contagious illness, such as COVID-19, medical doctors must know when to take extra precautions to mitigate the spread. For both patients and medical professionals, documentation is extremely important. It needs to be updated, thorough, and legible.
Accurate Billing
Patients (or their insurance providers) receive and pay bills for the medical treatment they receive. If medical documentation isn’t accurate or up-to-date, patients may not receive their bill on time, potentially leading to it being sent to collections. As a result, their healthcare provider may be unable to provide care due to delinquent accounts. They may also receive billing that is inaccurate; for example, being billed for an MRI with contrast will cost more than without, and errors can result in unnecessary out-of-pocket expenses for patients. Translation or dictation errors can be common in billing, resulting in frustrating errors or inadequate compensation for treatment. Insurance companies may not pre-approve expensive treatments if medical documentation isn’t precise.
Traveling to Foreign Countries
Many countries require proof of vaccinations against certain diseases before entry. An outdated or inaccurate medical vaccination record can ruin a vacation or business trip in an instant. In countries where different languages are spoken, incorrectly translated medical documents may harm a traveler’s ability to cross the border legally.
Evidence in Legal Investigations
Medical treatment documentation often plays a crucial role in a court of law and can become vital evidence for attorneys, judges, juries, and law enforcement. For criminal investigations and civil lawsuits, medical documentation proves that certain treatments were administered at specific times by specific doctors. Documentation is very relevant in abuse cases where law enforcement needs to prove that a victim sought help. In sexual assault cases, medical documentation can prove when an assault examination took place and how effective it would be at the time it occurred. It’s also very valuable in medical malpractice cases, as it helps prove when and how medical errors occurred. Case studies show that medical documentation was vital in proving sexual abuse in a particular lawsuit against a Michigan youth residential facility, where victims received medical treatment from the perpetrators. If medical documents are missing or inaccurate, it can destroy an entire case. It can be the difference between a victim getting justice and a criminal receiving a proportional punishment. Healthcare providers must ensure that documentation is up to date, accessible, and delivered in a timely manner. Medical documents in foreign languages must be translated accurately to be applicable in legal settings.
School or Work Onboarding
Certain schools or jobs may require a clean bill of health or proof of vaccinations before entry to prevent the spread of diseases or to ensure the safety of individuals on the job. Drug testing, blood testing, or vaccinations are often required for jobs that involve foreign travel or physically demanding labor, such as those in the armed forces. If medical documentation isn’t accurate, it can affect one’s ability to join the military, start a degree program, or be hired for a particular job—this can massively impact one’s livelihood and entire career.
Time Saved at the Doctors
Thorough medical histories require doctors to spend time obtaining information from patients. If these medical documents aren’t properly stored or created, it wastes time for both patients and doctors to retake a history. When records are accessible, legible, and up-to-date, a significant amount of time is saved in healthcare clinics. In serious medical situations, saved time can save lives.
Pregnancy Health Planning
Certain health conditions are genetic, meaning they can be passed on to one’s children. Complete and accurate medical documentation can help expecting parents prepare and test for any genetic or heritable conditions that their baby might have. Inaccuracies can result in lost time, stress, and unnecessary expenses. Medical histories are extremely important for both the baby’s and the parents’ health.
Reduced Disease Spread
Diseases like measles or COVID-19 may not be deadly to everyone, but they can cause serious harm to young children, older adults, immunocompromised people, or disabled people. Accurate medical documentation helps healthcare teams and patients understand the exact moment when they test positive for these contagions, allowing them to take precautions to mitigate the spread. Inaccurate or outdated medical histories may not accurately reflect these test results, increasing the chances of spreading contagious diseases to others. Spreading disease in the wrong area or to the wrong population can cause many preventable deaths.
Fulfilling Advance Directives
When medical emergencies happen, patients may create advance directives (a living will) to appoint someone to make decisions on their behalf if they are otherwise incapable. A coma is a good example of medical incapacitation where a living will can come in handy. If medical professionals do not receive accurate advance directives, they may unknowingly act against a patient’s wishes. Some patients do not wish to be resuscitated in the event of a medical emergency. If these medical wishes are ignored due to poor or inaccurate documentation, it can be very distressing for them. It can also cause legal consequences in some cases.
Conclusion
Medical documentation isn’t solely a formality. Treatment logs, medical histories, medication lists, and billing documents all provide doctors and patients with valuable information that can save lives. Medical information can even serve as evidence in criminal or civil legal cases. Your healthcare provider should ensure that your medical documents are easy to read and accessible at all times.
