The importance of the medical record: a critical professional responsibility
Ngo E, Patel N, Chandrasekaran K, Tajik AJ, Paterick TE. The Importance of the Medical Record: A Critical Professional Responsibility. Journal of Medical Practice Management. 2016;31(5):305-8.
Comprehensive, detailed documentation in the medical record is critical to patient care and to a physician when allegations of negligence arise. Physicians, therefore, would be prudent to have a clear understanding of this documentation. It is important to understand who is responsible for documentation, what is important to document, when to document, and how to document. Additionally, it should be understood who owns the medical record, the significance of the transition to the electronic medical record, problems and pitfalls when using the electronic medical record, and how the Health Information Technology for Economic and Clinical Health Act affects healthcare providers and health information technology.