The Importance Of Medical Practice Documents

Filled under: Healthcare Compliance on November 2012

All documents used within a medical practice, regardless of their type are regulated by state and federal laws. Medical documents may be handled differently depending on two important factors. They are where the practice is located and whether the records are in paper or electronic format.

Medical practice documents can include:

  • Patient medical records;
  • Other medical practice documents;
  • Personnel files;
  • Payroll documents;
  • Tax reports;
  • Accounts payable;
  • Accounts receivable;
  • Documentation to support records.


To make sure that all medical records will be stored in the best conditions possible you should complete the following steps.

  1. Separate the documents you need to manage by different categories to make the whole process easier. These categories should include personnel documents, medical records, tax documents, payroll documents and accounts receivable.
  2. Personal documents are quite complex and can be really hard to handle. This is why they should also be divided into different categories. Such categories can include documents subject to audit, employee specific documents and employee medical documents.
  3. Make a separate category of documents that may be needed for compliance. 
  4. Make sure that patient records are secure and no unauthorized persons will gain access to them.
  5. Be careful at billing documents and paperwork.
  6. Use electronic medical record software for a simpler handling.
  7. Keep all documentation linked to the work of your private practice and be certain that patient records are complex.


Why is medical documentation so important? 

Without medical documentation, the entire healthcare system would be compromised. A doctor needs to know everything about the tests, treatments or surgeries, actually anything from the past of his patient, before setting a diagnosis or recommending a therapy. Medical documentation generally provides all the information needed for a doctor to know how to treat a patient.

The patient’s medical history is actually considered to be a vital piece of information that allows specialists to determine the best diagnosis possible, the most appropriate treatment plan, all based on the patient’s medical history.

And that is not all. Medical documentation is important from the financial point of view, as well. If a healthcare provider forgets to write something in a patient’s medical record, no matter if it regards a treatment, surgery or a simple procedure, the facility will not be paid for it. With no documentation, there is no proof that patients received any services.


Medical documentation and easy access to medical records can actually save patients’ life. For instance, in critical situations, a specialist has to know if the patient is allergic to a type of substance.

Adequate medical documentation can also ensure the patient’s confidentiality and that the standards of care are being met. Doctors have the obligation to treat their patients in the best manner possible and to offer them the right medical care. Otherwise, compliance claims can be filed.

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