Commonly accepted standards for medical record documentation 1 each page in the record contains the patients name or id number 2 personal biographical data include the address employer home and work telephone numbers and marital status 3 all entries in the medical record contain the authors identification. Medical records documentation title medical records documentation date 2014 12 01 providers should submit adequate documentation to ensure that claims are supported as billed for more information please refer to complying with medical record documentation requirements fact sheet . Essential information is documented in the healthcare record to ensure patient safety documentation is an essential component of effective communication given the complexity of health care and the fluidity of clinical teams healthcare records are one of the most important information sources available to clinicians. A well written medical record documentation template promotes patients and physicians best interests for different reasons these documents have been compiled and maintained by the health care providers and usually it is enforced as a licensing or confirmation imperative importance of medical record documentation
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