clinical documentation (healthcare)

Clinical documentation (CD) is the creation of a digital or analog record detailing a medical treatment, medical trial or clinical test.

Clinical documents must be accurate, timely and reflect specific services provided to a patient. Paper or digital documentation is often accompanied by supporting electronic files such as magnetic resonance imaging (MRIs) scans, X-rays, electrocardiograms (EKGs) and monitoring records.

Clinical documentation is used to facilitate inter-provider communication, allow evidence-based healthcare systems to automate decisions, provide evidence for legal records and create patient registry functions so public health agencies can manage and research large patient populations more efficiently. Clinical documentation is also used in the creation of longitudinal patient records (LEPRs), a type of electronic health record (EHR) that includes all healthcare information from all sources for an individual patient.

Billing and coding staffs for health care providers use clinical documentation when evaluating claims. To ensure there are no gaps in a patient’s clinical documentation, some healthcare facilities employ clinical document improvement (CDI) specialists to review each patient’s clinical documentation and make certain it is comprehensive. In the United States, billing departments are increasingly turning to clinical documentation improvement systems (CDIS) to improve the accuracy of clinical documentation and help ease transition to the ICD-10 diagnosis coding language.

This was last updated in September 2014

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