Medical documentation is an integral and very important part of any medical facility. The content is regulated by the Decree on medical documentation ↗, which also regulates the scope of keeping such documentation, its requirements and rules. Whether you are a general practitioner, a dentist, a plastic surgeon or have any other specialty, you must keep medical documentation correctly, as it is a key area of your practice.
There is a difference between „maintenance of medical documentation“ and „proper maintenance of medical documentation“.
Properly maintained medical can be your lifeline in a dispute with a patient, regulatory body or health insurance company. Having everything well organised and stored (archived) is the key to running a successful practice. And if you have to present your medical documentation to an expert witness, for example, there is no better feeling than having the expert witness declare that your documentation is completely in order. With the impending computerization of healthcare, properly maintained medical records are a prerequisite for fast and smooth computerization.
Price: from CZK 60 000 + VAT
First, we will need to take a look under the hood of your practice (medical facility) and review the current state of your medical documentation, your procedures for informing and communicating with patients, and your established treatment procedures.
If you're starting a practice from scratch, we'll ask for details about what you'll be doing, how you'll run your practice and what patient information you intend to record.
Which will not only comply with the law, but also with your specific requirements for running your practice.
We will check the current status and propose an optimal solution. If you are a new medical facility, we will prepare the documentation from scratch. We will need all relevant information from you about the scope of services you provide, your expertise and established procedures. We will take care of the electronic or paper medical records. We will also take care of important informed consents as part of the medical documentation setup.
We will prepare sample documentation, contracts with patients, set up the division of roles and the necessary processes. And once successfully set up, we can also organise training for all staff on how to work with the documentation.