Documentation
of all components of the health visit is required on
each child's medical record. The medical record chronologically
documents the
care of the child and is an important element in contributing
to high quality health care.
Carefully documenting each visit helps to:
Identify
gaps in preventive care
Enhance
both quality and continuity of care
Identify
health or developmental concerns and intervene early
Avoid
duplicative screenings and tests (when previous results
not documented)
Ensure compliance
with HealthCheck/EPSDT mandates
Facilitate
external chart review
Improve
data collection and evaluation
Maximize reimbursement
Provider
Tip: Legible Documentation
Avoid
medical mistakes and ensure that services are counted;
write legibly.
Document
what you do and make sure that anyone and everyone
can read it.
Remember,
"if it can't be read, it didn't happen!"
This concludes the Introduction to the Documentation section.
The next page contains information on The Standard
Medical Record Forms.
Documentation
of all components of the health visit is required on
each child's medical record. The medical record chronologically
documents the
care of the child and is an important element in contributing
to high quality health care.
