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Sample Essay on Documenting Care

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Sample Essay on Documenting Care

Documenting Care

The presence of complete, accurate, and clear documentation is helpful in promoting auditing for continuous quality management, reimbursement, and health care analysis. The assessment of quality health care relies on the availability of quality data. Since, poor documentation, and insufficient communication would hinder the health information exchange and quality management initiatives (Blumenthal & Tavenner, 2010). The maintenance of quality data offers the appropriate guidance and frameworks for understanding the integrity of the health care programs. The documentation helps to design and support the health information system as well as improving the management of electronic health data and information. The availability of accurate and complete documentation is aligned with the governmental and regulatory standards. This helps to facilitate proper medical growth and development in the health care sector. It further assists the health care by promoting the quality of care through the recommendations and conclusions obtained from the quality data and documentation. For instance, when the U.S is making substantial heath care reforms, it relies on the available documentation.

The actual and complete documentation guides the health care policymakers on making effective health care reforms. This can be illustrated by the “Health System Reform Agenda (2008)” developed in 2008. The reform agenda made an effective health care comparison using the available documentation (Doenges, Moorhouse, & Murr, 2013). The recent trend in documentation involves the hybrid health records that integrate the electronic heath record in health care analysis. The integration of HER helps to promote data review, abstraction, and coding. This offers reliable and analytical health care reports. The health care reports help to make appropriate health care decisions towards improving the quality of care. Therefore, the presence of accurate and complete documentation is helpful in promoting effective heath care analysis and continuous improvement in the health sector.


















Blumenthal, D., & Tavenner, M. (2010). The “meaningful use” regulation for electronic health records. New England Journal of Medicine, 363(6), 501-504.

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2013). Nursing diagnosis manual: Planning, individualizing, and documenting client care. Philadelphia, PA: FA Davis.


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