Accurate and good medical documentation promotes better medical care and patient safety. This is very important in all types of orthopaedic conditions including Spine Injuries. Recording all relevant information of a patient’s care on EMR or by dictating and getting it transcribed by a medical transcription company helps practitioners monitor what’s been done and also minimize the risk of errors in treatment. Keen attention to minor details reduces the chances of patients returning to the hospital.
Quality Medical Documentation for Disc and Ligament Injuries
As for any other disorder, accurate and timely medical documentation is important for spine injuries. Today, many insurance companies deny coverage for spine injuries or bone graft substitutes, but with error free medical documents reimbursement becomes easier. Neck injuries and cervical spine joints are also common injuries in car accidents. For proper treatment, imaging of spine is essential as it allows the provider to accurately diagnose the condition.
Every medical provider may have a license but specialization is important for more precise diagnosis, prognosis and management. To determine causality, the provider should identify as to what tissue is injured, and also use imaging for age-dating to determine when this injury occurred. In fact, proper physical evaluation and documentation of the cause of the injury is crucial to support a comment on the cause of the injury.
For example, take disc herniation. In a study on the classification of lumbar disc pathology published in 2001, the authors pointed out that simply reporting the term ‘herniated disc when documenting spine injury does not “infer knowledge of cause, relation to injury or activity, concordance with symptoms or need for treatment”. In the absence of significant imaging evidence of associated violent injury, disc injury should be classified as degeneration rather than trauma. This will allow trauma trained doctors to proceed with the treatment on the basis of clinical findings, and the understanding the every patient’s physiology is unique.
A disc is a ligament connecting a bone to bone and it has structural responsibility to the vertebrae above and below to keep the spinal system in equilibrium. Therefore a minor damage to disc can cause abnormal load bearing forces at the injury site and other health issues. Therefore, accurate medical documentation of spine injury is essential for timely diagnosis and appropriate therapeutic interventions.
Accurate and timely documentation through EMR or medical help in creating error medical documentation, which ensures the following benefits:
- Assures continuity of care as it serves as a communication tool among healthcare providers
- Allows proper evaluation of the patient’s condition and planning of treatment
- Creates a permanent record for patient’s future care
- Substantiates billing
- Create a database to evaluate effectiveness of treatment
- Useful for justifying or defending care provided
- Facilitates research
Documentation is always critical for continuity of care of spine injuries as well as in medical billing and coding for the same.
