Patient Documentation

Patient documentation refers to the careful and accurate recording of a person’s health information by healthcare providers. It includes details about medical history, diagnoses, treatments, medications, and progress over time. This documentation ensures that all healthcare team members have up-to-date information, facilitating safe and effective care. It also serves as a legal record and can help in coordinating future treatments. Good documentation is clear, complete, and timely, supporting communication among providers and improving patient outcomes.