Question

What is the most important reason that the health record is considered a critical document in healthcare delivery?

Answer 1

Health record plays an important role in the health care system. The treatment, procedures, other cares are recorded by doctors, nurses, and other healthcare professional. It is also maintained as the legal document to protect the patient's rights and privacy. Nowadays, the electronic form of data saves several data till the patient's death. It maintains and stores individual health record separately. Not only the patient, but it also protects the healthcare professional from legal issues. So entering the accurate information in a correct way at a right time is the first critical thing. The documenting of efficient information that is clinically relevant information is essential.

Secondly, the documentation increased the risk due to the wrong patient identification and documentation. Addition of extra procedures or tests increases the billing cost of the patient. Healthcare data lead to healthcare fraud if the patient's data are misused by other staff members. Thirdly, Making good clinical judgment in the treatment of care is critical. The fourth one is a failure to document the expert witness in case of emergency treatment leads to a malpractice situation. The clinical documentation should be clear and should not attempt to change the record. In a simple way, the health record should be documented with proper principles and guidance and it should be a solid valid record.