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Although a lot of money is spent on administration and other maintenance work, quite often the same attention is not given to clinical documentation.
With increasing number of patients visiting hospitals and clinics, efficient health care would be difficult without proper documentation especially for the follow-up visits.
Clinical documentation done in paper files can often be misplaced or lost and this could cause serious health problems to patients due to the lack of complete records.
With the advance in technology, clinical documentation is now digitized, automated and much more efficient to handle.
With computers and other digital storage systems, practitioners can now ensure privacy of the patients' information and the protection of all the records.
This clinical documentation allows easy storage and retrieval of patient's records at the time of requirement and also as many times as required by the attending health care professional.
Scans, tests and reports of the patients can now be stored electronically.
Archiving paper-based documents that are stored electronically is now possible providing faster and accurate access to all patient information improving diagnosis and health care.
Clinical documentation of data collected on sickness, diseases, treatment and analysis can be published and accessed globally.
This could help in developing cure for conditions that have no cure yet.
Electronically stored documents can now be used to transfer records to hospitals or medical professionals across the globe through the internet to get a second opinion.
Documents can be transferred for referrals of patients from one medical center to another.
Results of various tests, prescriptions and lab results can be passed on in a quick and efficient manner for improved health-care to the patient.
Health-care professionals can track information on patients efficiently and accurately without having to move around rooms and departments.
The benefits of clinical documentation are many.
It facilitates improved and effective clinical care for every patient who is in need of health care by having individual records stored for access anytime and anywhere they are required in a quick and accurate way.
This can result in improved teamwork and cooperation among health care professionals.
Complying with government requirements and regulations will become more efficient and effective.
Processes such as patient's test, lab and treatment records, billing and insurance claim and eligibility can be streamlined.
This way clinics and health care professionals can ensure higher satisfaction of their patients.
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