How Effective Is Your Medical Documentation?

Medical record-keeping is all about documentation! Our paper-based health records demand quality, and should therefore be more legible and complete.

In India, medical records are still primarily paper-based. Each one is a detailed account of a patient's health history, which includes current illness, clinical findings, and treatment, among other information. It is very important that the treating doctor properly documents patients' clinical data and medications prescribed. Often, we encounter that the record is not legible because of the use of abbreviations and bad handwriting. Essentially, each record is a patient's medical story, taking us through their past to lead us to the currently presenting illness or condition of health.

Variation in Documentation Practices

A common occurrence is that there is a lot of variation in medical record-keeping. Hospitals design their own formats and follow their own policies to maintain patient data. The process of keeping medical records in hospitals is very comprehensive and exhaustive.
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