Why Documentation is Important ?

Just like the payors continue to get miserly to pay the doctors, the hospitals are facing such problems too. The video news content is worth watching. If you do not document a decubitus ulcer if present on admission, in your History and Physical, Medicare may assume that it developed in the hospital and not pay for its care at all. Surgeons already do not get paid for the care of most complications from the surgery. Even from medico legal standpoint, such observations should be noted in the initial H&P. For example a lawsuit claiming that hospital was responsible for decubitus ulcer was quickly dropped, after a note in the H&P stated that it was present on admission.