Abstract
As health care delivery changed and the volume and complexity of treatments advanced, so did the requirements and guidelines for medical record documentation. Comprehensive health documentation management in today’s modern culture involves adherence to a multitude of Federal and State regulatory requirements, compliance with various accreditation bodies, and professional practice standards, and organizationally developed policies. Together these requirements work to result in comprehensive health record documentation that includes information pertinent to the care and treatment of the patient in order to promote continuity of care, justify the care that was rendered, and provide evidence for medical necessity, patient education, billing compliance, and defense against litigation. Today, this effort presents an ever-increasing need for stewardship and integrity for the information that is gathered so as not to proliferate data in the absence of sound treatment information.
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Howe, J.L. (2019). Standards. In: Onyejekwe, E., Rokne, J., Hall, C. (eds) Portable Health Records in a Mobile Society. Health Informatics. Springer, Cham. https://doi.org/10.1007/978-3-030-19937-1_3
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DOI: https://doi.org/10.1007/978-3-030-19937-1_3
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