Accurate and complete documentation is important for ensuring quality care and patient safety by communicating consistent information to all members of the care team along the treatment continuum. It is also crucial that the medical record accurately reflects the complexity of care that was provided to the patient as it informs planning and ensures appropriate reimbursement.
In 2017, the second edition of the National Safety and Quality Health Service (NSQHS) standards developed by the Australian Commission on Safety and Quality in Health Care (ACSQHC) acknowledged that communication errors are a key safety and quality issue. The Commission gave evidence that poor documentation caused errors, misdiagnosis, inappropriate treatment and sentinel events. It also acknowledged that missing information or miscommunication contributed to higher readmission rates and inappropriate follow up after discharge, all of which impact patient outcomes and increase costs.