Consequences of Incomplete Patient Documentation

» Articles » Medical Records Articles » Article

April 12, 2022
Author: Lorman Education

Patient documentation is an essential part of medical care. Paperwork is used to compile information on a certain person, the treatment he or she received and personal information for billing and other necessary purposes. While filing the proper paperwork may seem easy to overlook, the consequences of incomplete patient documentation are vast. In fact, a practicing doctor can lose his or her license by forgetting to note a certain discussion.

In many ways, an incomplete medical record demonstrates that care was improperly administered, and can be used to support allegations of negligence and fraud. As a result of poor paperwork management, a doctor can cause a loss in revenue at his or her practice, lead to inappropriate billing, interfere with patient-related studies and result in costly treatment methods.

Doctors need to pay close attention to how medical paperwork is filled out, because the documents are an important and necessary part of the overall health care process. If a patient is unsatisfied with the result of certain treatments, patient documentation may serve as a doctor's defense, as the forms often outline the care that is to be administered and require a patient's signature. 

The material appearing in this web site is for informational purposes only and is not legal advice. Transmission of this information is not intended to create, and receipt does not constitute, an attorney-client relationship. The information provided herein is intended only as general information which may or may not reflect the most current developments. Although these materials may be prepared by professionals, they should not be used as a substitute for professional services. If legal or other professional advice is required, the services of a professional should be sought.

The opinions or viewpoints expressed herein do not necessarily reflect those of Lorman Education Services. All materials and content were prepared by persons and/or entities other than Lorman Education Services, and said other persons and/or entities are solely responsible for their content.

Any links to other web sites are not intended to be referrals or endorsements of these sites. The links provided are maintained by the respective organizations, and they are solely responsible for the content of their own sites.