Importance of Record Keeping for Medical Professionals

 

Author: Jordan Larkin

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Medical professionals such as physical therapists, athletic therapists, surgeons or doctors all share a common practice that is important for patients, record keeping. Have you ever asked yourself why this practice is so important?

When an individual hears or thinks of a medical profession, many often overlook the important detailed duties that each professional performs daily. Record keeping is one such duty yet is an essential part of being a working in the medical field. Medical records, physical records and exercise records are key components in deciding what type of treatment, rehab or prescription the patient needs.

Recognizing the importance and legal and accurate records is a standard for all medical professionals as they have an obligation to protect and care for the patient. An individual’s records can provide valuable information for the medical practitioner.

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For instance, records can show evidence of informed consent, past medical history, current prescriptions or past treatment performed on the individual. Records can also facilitate communication between health care professionals as a patient might see multiple healthcare professionals for a certain issue.

Keeping track of the data allows for the medical professional to make the best diagnosis. It also allows for the professional to develop an accurate game plan so the patient can improve rapidly.

Bottom Line

If you are thinking of working in the healthcare field, prepare to have to maintain accurate, detailed records of patients. This will help you learn, maintain safe health records for patients, and help you make the best decision for treatment. Make sure you’re thorough!

References:

American Physical Therapy Association. (2009, December 14). Guideliines of Physical Therapy Documentation of Patient/Client Management. Retrieved from Documentation Management: https://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/BOD/Practice/DocumentationPatientClientMgmt.pdf

World Confederation for Physical Therapy. Policy Statement: Standards of physical therapy practice. London, UK: WCPT; 2011.  (Access date 22nd September 2011)